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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 />City Lot Size i ro XI ; 0_ PM <br />Job Address Ka��-�� <br />- r _—. ........ __ V k Phone <br />Owner's Name res - ti <br />Contractor's Name <br />License <br />�. Phone <br />No. <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTHUt:I LUN u <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ .� OTHER <br />DISTANCE TO NEAREST: <br />SEPTIC TANK <br />SEWER LINES DISPOSAL FLD. <br />PROP. LINE <br />FOUNDATION <br />AGRICULTURE WELL OTHER WELL <br />PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTiON SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom- <br />❑ Manteca Dia. of Well Excavation <br />Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack. <br />❑ Tracy Type of Casing <br />Specifications <br />❑ Public <br />❑ Other <br />❑ Delta Depth,of Grout Seal <br />Type of Grout_ <br />❑ Irrigation • <br />—Approx. Depth <br />❑ Eastern Surface Seal Installed by' <br />w <br />Repair Work Done ❑ <br />-Type of Pump <br />H. P. State Work Done <br />Well Destruction ❑ <br />Well Diameter <br />Sealing Material Stop 50') <br />Depth <br />Filter Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Fq ' DESTRUCTION ❑ iNo septic witrmiitled if public sewer is <br />availabInstallation will serve: Residence �—---Commercial7-7-7 "'Other <br />Number of living units: Number of bedrooms Z_ <br />Character of soil to a depth of 3 feet: Water table depth _ <br />s <br />f <br />f <br />LEACHING LINE j]�_No. & Length of lines t V Total length/size <br />FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS Depth .J Size Number <br />SUMPS ❑ Distance to nearest: Well Foundation Property Line o <br />DISPOSAL PONDS :. ❑ <br />I 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 />a <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 <br />certifies the following: "I certify that in the performance of the work -for which'this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant call for all required inspections. Complete drawing on reverseAr <br />'de <br />Signed - - - Title: Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by v" Date Area <br />7 Ire i Z Date 1? 7 <br />Pit or Grout Inspection by a�f� Date Final Inspection by ,q <br />Additional Comments: c`CAI�`f�rA��aa ,� ✓���A!fiG��� <br />❑ Stk 466-6781 C1 Lodi 369-3621 x ❑ Manteca 823-7104 ❑ Tracy 835-6385Ave.,. <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton ., P.O. Box 2009, Stk., CA 95201 f'/� 1 <br />FEE AMOUNT DUE AMOUNT REMITTED CASH - RECEIVED BY DATE PERMIT'NO. <br />s CK <br />INFO - - — jl ,, `fir <br />+ EH 13-24 (REV. 10/S31 *'x# L. . -.1 �+�.: ti, � � % �.tA/$- �'-1" rP <br />a EH 1428 y ' O <br />IS <br />F_ <br />U1 <br />