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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED : <br /> (Complete in,Triplicate) <br /> `r,� {Srt <br /> Application is heieb made to the San Joaquin Local Health District for a permit to construct and/or install the w[ I�-�aiftS4$S��jjlralzed. hiv` pplication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules6 egufalti6 of tie San Joaquin <br /> Local Health District. <br /> Job Address 4 N 5 9, ,� ^ jL.City ACQ t Lot Size PMf <br /> Owner's Name Address IOL t7y / 1p Q I�t • r -;_44- Phone 3 ?1:5�6 <br /> A-CS 157-4r6g (-A <br /> 3139 <br /> Contractor /�' I� Address qjPhonee <br /> R <br /> TYPE OF WELL(/PUM�V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION �I SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 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 lei Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.-Approx. Depth I 1 Eastern Surface Seal Installed by _ - <br /> Repair Work Done L] Type of Pump �y!3 H.P. -17 — State Work Done�'Af 1 N1 0 [�u I1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f] REPAIR/ADDITION I 1 DESTRUCTION t I (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 Capacity No. Compartments \ 4 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal v�4 <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 i I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di%trict. <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 applicant must call f all required inspections. Complete drawing on reverse side. <br /> SignedX Title: Date: 19- <br /> F PARTMENT USE O LY <br /> Application Accepted by Date, `�2Area <br /> Pit or Grout Inspection by Date Final Inspection by Date/ <br /> ' Additional Comments: 7 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-W05 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> J <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 0 ASH RECEIVED BY DATE P€RMIT'NO. <br /> INFO <br /> +.EH13-24{REV.F/n 51LA <br /> �� <br /> EH 14-29 , I <br />