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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ~ <br /> a <br /> Telephone {209) 466-6781 i <br /> PERMIT EXPIRES 1 YEAR FROM DATExISSUED ,I, <br /> ' r y '(Complete in Triplicate) sApplication is hereby made to the San Jolin�� <br /> Local Health District for a permit to construct and/or install the work herein described. This application is <br /> t made in compliance with San Joaquin County Ordinance No:549 for sewage or No. 1562 for well/pump and'the Rules and Regulations of the San Joaquin <br /> Local Health District. ' <br /> Job Address <br /> /Vl U�iE4/� r City of Size .PM <br /> /� �j Q f <br /> Owner's Name "J%P+fi �!e� A'dress' -:3a _ Or <br /> Phone [� T 'c7 f� <br /> t Contractor Address _ 4 <br /> License No. 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 DISPOSAL FLD. i' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial -1'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' s T <br /> ype of Grout <br /> ❑ Irrigation <br /> ---Approx. Depth. ❑ Eastern } .Surface Seal Installed by I <br /> t v , <br /> Repair Work Done C1 Type of Pump H.P. State Work pone <br /> a <br /> Well Destruction ❑ Well Diameter f Sealing Material (td-p-50') + i <br /> Depth F Filler Material (Below 501 ► <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION-S(No septic system permitted if public sewer is <br /> i { available withiri'200'feet.) <br /> Installation will serve: Residence— Commercial Other F c <br /> e_ <br /> Number of living units: of tuber of bedrooms '*- 4 1'. �` <br /> Character of soil to a depth of 3 feet: t <br /> Water table depth ( <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance tonearest: Well Foundation Property Line I <br /> LEACH ING'LINE`�n' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ? <br /> i ! , <br /> SEEPAGE PITS ❑ Depth T '-Size M � C"Nu )ber, r- <br /> SUMPS ❑ Distance to nearest: Well' : "Y,Foundafsbn� Property Line <br /> DISPOSAL PONDS ❑ t t a <br /> I hereby certify that I have prepared this application-and-that the-work will-be done-in-accdrdance 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 /> T pl'cant m t call for all 'e inspections. Complete drawing on reverse side. <br /> 77Signed X Title: Date:' <br /> Y FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date uU Area LL <br /> Pit or Grout Inspection by Date Final Inspection by Date-4-5 <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 , ❑ Manteca a23-7104 5 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 i <br /> INFO , AMOUNT REMITTED CK RECEIVED BY' DATE PERMIT NO. <br /> + EH 13-24(REV. J ` <br /> EH 14.26 F/4- <br /> k� 1yS; - ' <br />