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APPLIC TIONIFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> '31 10 -t;- <br /> D <br /> 'PERMIT EXPIRES 1.YEAR FROM DATE ISSUE }1 �� ,, <br /> r.: (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. yn:, <br /> Job Address ` 7 L! G I'3 Ti) r , City / --tot Size PM <br /> Owner's Name 1,[ Address es lNi..._-.�_ Phone _ <br /> Contractor's Name 14 tG - G. GLicense No. Phone K�a <br /> TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-D <br /> • PUMP INSTAL LATIO ❑ SYSTEM REP.AIR�X OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Y� _•DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 'AGRICUL7URI:WELLY '' OTHER WELL PITS/SUMPS _— <br /> INTENDED USE. TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom - .-11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N1 Domestic/Private _ ❑.Gravel Pack ❑ Tracy Type of Casing_ Specifications r <br /> ❑ Public -- `- ❑ Other ❑ Delta Depth of Grout.Seal Type of Grout <br /> ❑4rrigji& u --Approx. Depth. �❑ Eastern Surface Seal Installed by <br /> Repair Work Done IX. . Type of Pump .7�-_-... H.­P- <br /> �:­ } State Work Done v� <br /> Well Destruction ❑ Well Diameter t Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 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 Cap cF 'No.Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ..Foundation---- _- Property Line <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size I <br /> FILTER BED ❑ Distance to nearest: ell +� Foundation Property tine <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> 'SUMPS I ❑ Distance to nearest: Well Foundation_ Property Line <br /> DISPOSAL PONDS ❑ ' Y'f <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 applica call for all require pections Complete drawing on reverse side. <br /> Signed ft Title: �P"F'S Date: <br /> .1 FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by t Date Area <br /> Pit or Grout Inspection by 4 Date tFJ,.,lspection by <br /> Additional Comments: — -- <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED r CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> I i r <br /> +fH1324(REV.10!831 ! Z� moi! t d <br /> EH 1426 SAO^+4 <br /> t <br />