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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I 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. 1852 for well/ <br /> Local Health District. pump and the Rules and Regulations of the San Joaquin <br /> r <br /> Job Address 1�:��c`�� ,vy�� 1 T <br /> City Lot Size PM <br /> Owner's Name Address Z-1 � Phone) �' >l 74 <br /> Contractor Address c� 7 �- 6 JJ <br /> License NoA- �? Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> --� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL { OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL (PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS \� <br /> ❑ Industrial <br /> —[].Open Bottom_—,1D-Manteca__ <br /> C3`Domestic/Private Excavation - a. of Well Casing sing <br /> L1 Gravel- ❑ Tracy Typeof Casing11 Public ❑ Other ❑ Delta Specifications <br /> phof Gout <br /> �1 <br /> i <br /> Seal Type of Grout <br /> ❑ Irrigation -�pprox. Dept E3 Eastern Surfpce Seal Installed by k <br /> Repair Work Done ,B' Type of Pump H,P. f State Work Done <br /> ¢ Well Destruction ❑ Well Diameter Sealing Materiali{top 50'1 <br /> Depth Filler Material (Below,50') 'a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ (No septic stem <br /> ti p y permitted if public sewer is <br /> available within 200 feet.) :, <br /> Installation will serve: Residence_4 Commercial_ Other, __ f <br /> Number of living units: Numb r of bedrooms ` .r <br /> Character of soil to a depth of 3 feet:. <br /> * SEPTIC TANK ❑ Type/Mfg —Water table depth \�f <br /> _Opacity No. Compartments <br /> 'PKG. TREATMENT PLT. 71 � s <br /> Method of Disposal <br /> yDistance to.nearest: Well Foundatiol <br /> n�_ Property Line <br /> LEACHING LINE 10, No::&'Leng'th of lines i <br /> Total length/size <br /> FILTER BED 4 ❑ Distance,to nearest: Well Foundation" Property Line <br /> �_..-•ter .. ( i <br /> SEEPAGE PITS ❑ Depth i Size ) Number <br /> SUMPS ❑ Distance tol nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared tfYis..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: <br /> em to an g: "Ice�fy that in the performance of the work for which this permit is issued, !shall not <br /> ploy y 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 ca or all required ' spections. Complete drawing on reverse side. <br /> Signed <br /> isle: Date: <br /> FOR DEPARIMENT USE ONLY <br /> Application Accepted by Date Area c/ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> - Dat e,Ly 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi. 369-3621 ' ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE t <br /> AMOUNT DUE AMOUNT REMITTED CASH DATE AERMfT N0. <br /> INFO CK RECEIVED BY <br /> + EH 13-24(REV.t/55) f <br />