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i APPLICATION FOR PERMIT <br /> !j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 4 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I PERMIT EXPIRES '!•YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San J"oaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> r 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 /> I Local Health District. > <br /> �w c ( <br /> Job'Address. <br /> " <br /> - �O'` <br /> ty Lot Size PM <br /> Owner's Name Address HtiW QQW't&Otl k1 D <br /> �.p I Phone <br /> � <br /> Contractore'`t %,NN4�ryl t.t I Address �?C�O$ c.",r1License No.��g�`3� 9{6 –���(.C� <br /> TYPE OF WELL/PUMP: NEW WELL Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER INrfh"f}W31' well] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 k/W <br /> 'Gravel Pack Dia. of Well Casing <br /> ` �Domesti Priv ❑ Tracy Type of Casing �– <br /> l"I Public nOther Specifications fQ18 i <br /> Cl Delta Depth of Grou <br /> I Irrigationt Seal �+ Type of Grout <br /> ! --Approx. Depth I I Eastern <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P <br /> State Work Done� <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') iz; I C ,q�"I` <br /> Depth V'A�"tll.+r M1 <br /> p I Filler Material f Below 50'1 8 C-rC� Wedgy <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION i I REPAINfADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is ! <br /> Installation will serve:' Residence J Commercial available within 200 feet) <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I <br /> SEPTIC TANK Water table depth <br /> ❑ 'Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: Well Foundation Method of Disposal <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of tines <br /> � Total length/size <br /> FILTER BED <br /> ❑ Distance tc nearest: WellFoundation <br /> � Property line <br /> SEEPAGE PITS ( I Depth 3 Size <br /> SUMPS — Number <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line y <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: "l 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 ust call for all required inspectio . Complete drawing on reverse side. <br /> Signed Title: 6 <br /> Date:/G <br /> FOR DEPARTMEN USE ONLY ! <br /> Application Accepted by <br /> Date AreaP ,_ <br /> Pit or Grout Inspection by i <br /> Date Final Inspection by Date <br /> Additional Comments: { <br /> f ❑ Stk 466.6781 ❑ Lodi 369-3621 ' ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE jPERMIT NO. <br /> + EH 13-24{REV,i i n 5f <br /> EH 14-2B <br /> _ / 6 -3 b I <br />