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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k <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/pumppind the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> /,�" A+.��/� <br /> Job Address _r,y-er of- 17 ;crtn c� �O/iC"s <br /> City Lot Size PM <br /> Owner's NameC c7�v J C fc Grp"l r' Address Phone <br /> a� <br /> Contractor ,V f" 111a Address_ /,/1 ley%.—e _License No.rI 1.14 2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ s WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST%SEPTIC.,TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION ice=- AGRICULTURE`WELL ""r. OTHER WELL PITS/SUMPS <br /> INTENDEDUSEt 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 ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter: Sealing Material (top 50') _ � � 7p Q�llg1Z/ A-Z/ <br /> Depth Filler Materiat (Below 50') 1-n A Yo aC A' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other t <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 CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to:nearest: Well Foundation Property Line <br /> II <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well i Foundation Property Line <br /> SEEPAGE PITS ❑ Depth to Size �" Number j <br /> SUMPS ❑ Distance to nearest: Well) Foundation Property Line <br /> DISPOSAL PONDS ❑ I J _ <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 /> k 1 <br /> The applicant muul call for allrequired inspections. Complete drawing on r arse side. <br /> Signed l Title:— � Date: <br /> _ k. <br /> FOR DEPARTMENT USE ONLY " <br /> Application Accepted by +' }' Date rea <br /> Pit or Grout Inspection by Date Final Inspection by O Dat* <br /> O <br /> Additional Comments: e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 83540ffi <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> `.v Y <br /> k AFEE . <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY ,PATE PERMIT''N0. q <br /> EH 13-24MEV.1/851 14 <br /> EH 14-28 <br />