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t <br /> J I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA - <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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.50 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 'Job Address 12660Vl. Rdildl® Rd. City Tracy. Lot Size PM <br /> Owner's Name re '&: - Address Phone y <br /> Contractor's Name 170Ug W11SOlz FL1T,ti't:6 ' License No. <br /> 64921. Phone 83 6-2 787 <br /> TYPE OF WELL/PUMP: NEW WELL❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION$7 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKI SEWER LINES DISPOSAL FLD. PROP. LINE + <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ! <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other F . ❑ Delta Depth of Grout Seal Type of Grout l <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by O r <br /> Repair Work Done ❑ Type of Pump'1 gnib H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter l Sealing Material {top 501 <br /> Depth f Filler.Material (Below,50') r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is tj <br /> �r available within 200 feet.) <br /> Installation will serve: Residence— ,,Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: " Water table depth <br /> SEPTIC TANK ❑ Type/Mfg!f I Capacity No. Compartments - <br /> PKG. TREATMENT PLT. ❑ Method of Disposal S�✓ <br /> Distance to nearest: Well Foundation b. * Property Line i <br /> LEACHING LINE ElNo. & Length of lines Total length <br /> /size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS ❑ Distar 66-tolnearest: Well Foundation Property Line <br /> I 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 /> 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 must call for all required inspectons.-Complete drawing on reverse side. -� <br /> Signed }� Title: Date: t]d...1 f-AS <br /> •Ir <br /> FO EPARTMENT USE ONLY D <br /> Application Accepted by Date' , Area <br /> f ~ <br /> I Pit or Grout Inspection by Date Final Inspection by J Date,J <br /> Additional Comments: ,) <br /> ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> +EH 13-24(REV.101831 <br /> 4 EH W28 <br />