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. � APPLICATION FOR PERMIT - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in .Tdplicate) <br /> l <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 /> f 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. /f .. T ,[ j , /� _ a�,, <br /> Job Address - +�`�� ��/ + '�— CityVi �d�/ Lot Size �'T^r'PM <br /> Owner's Name v 0, �r� ress� . �s2 d��/" %U/ - �/ U s" Phone A ~��� <br /> .L1 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION _ t' <br /> PUMP INSTALLATION ❑ " 4 ¢SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 90 SEWER LINES " DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> e ^ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications <br /> 4❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> .❑ Irrigation NR --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done, 0 r Type of Pump H.P. State Work Done_ �J <br /> i Well Destruction Well Diameter Z�"'�'�1 Sealing Material (top 501 C <br /> Depth YQO + d/ Filler Material (Below 501 -�— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 6 <br /> available within 200 feet:)-- <br /> Installation will serve: Residence Commercial_ Other + 6 <br /> Number of living units: Number of bedrooms <br /> f. <br /> Character of soil to a depth of 3 feet: � � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ yy E r Method of Disposal <br /> Distance to nearest: Well` Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER.BED ❑ Distance to nearest: Well " Foundation Property Line <br /> SEEPAGE PITS ❑ Depth [ ` $ Size Number r <br /> i SUMPS ❑ Distance}to nearest WellFoundation Property Line <br /> DISPOSAL PONDS ❑ I e.i `r 'a< { <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-contiacting 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 for all required insS�__T­Itle: <br /> s. Complete drawing on reverse side. Q� <br /> Signed Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2,,f— Area .6 <br /> Pit or Grout Inspection by Date Final Inspection by &�ADate `J <br /> r <br /> Additional Comments: t <br /> ❑ Stk 4664781 - ❑ Lodi 369=3621 ❑ Manteca 823-7104 ❑ Tracy 8354i3% <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(RE1/.1/85) <br /> EH 14-28 <br /> f <br />