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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address I S ,o7 G <br /> Owner's Name <br /> M -T. I City Pft" Lot Size PM <br /> 2Z-AJ � <br /> /�4L1 1 rR1tJ % adl 1 FF�� <br /> , Phoneme- a t� <br /> Contractor's Name i. L`1el.,e SlL� _ License No. 7 �� � <br /> TYPE OF WELL/Pt1MP: NEW WELL ❑ Phone. <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 'M SYSTEM REPAIR Q <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER 71SEWER OTHER <br /> FLD. <br /> PROP. LINE <br /> �---• ------ - _ FOUNDATION AGRICULTURE WELL. <br /> OTHER WELL L1 ._ .PITS/SUMPS-`-.---1— <br /> INTENDED USE TYPE OF WELL-_ PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial _ 13 Open Bottom El Manteca �+ <br /> Dia. of-Cas Excavation Dia. of Well Casing <br /> Domestic/Private R [ Gravel Pack = '�❑ Trac <br /> Y `Type of Casing Specifications <br /> ❑ Public El Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Type of Grout <br /> ]Surtace Seal InsL,:- State <br /> '\3 <br /> Repair Work Done Type of Pump �� H.P. <br /> Well Destruction ❑ Well Diameter Work Done -1?0 oue �S„ Lipubiric <br /> Sealing Material (top 50') l•, kJDepthFiller Material (Below 50') 0449 l,�/1 ]' � �TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DE57RUCTION ❑ (Noseptic system permittedif sewer is V <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercial_ Other <br /> Number of living units: Number of bedrooms-, <br /> Character of soil_to a depth of 3 feet: <br /> SEPTIC TANK — _ -� Water table depth <br /> ❑� Type/Mfg - Capacity__ No. Compartments <br /> PKG. TREATMENT PLT, ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line. <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED f Total length/size <br /> ❑ Distance to nearest:° Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number V t <br /> ❑ Distance to nearest: Well - Foundation <br /> DISPOSAL PONDS ❑ _ Property Line <br /> 1 hereby certify that I have prepared this-application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature F <br /> certifies.the_foilowing:"I certify that in the performance of the'-work for which this permit is issued, I shall employ I <br /> tion laws of California." p y persons subject to workman's compensa- <br /> The-applicant pt call for�reed-ipections: Complete drawing on r rse side. <br /> Signed <br /> Title: pate: --�_ <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by � <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection b <br /> Additional Comments; .t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 i JULt,Q� <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.�95401C � L � <br /> �f3<tr <br /> `d <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CASH RECEIVED BY ;��;DLNE? <br /> 1 f1' f <br />+ EH 13-24IREV.10/$31 - <br /> EH 1426 • q� - <br />