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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCALHEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete Triplicate) , ^ - •.L;," <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> 4}ra <br /> Lot Size PM <br /> Job Address r r. City y <br /> Phone <br /> Owner's Name Address - --" <br /> + v . <br /> t -119 <br /> Contractor Address a�� v License No�S Phone <br /> TYPE OF WELL/PUMP: ` NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 'PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE:-TO,NEAREST:-4SEP�ICsTANK - ""` SEWER LINES' DISPOSAL FLD. PROP. LINE <br /> FOUNDA_TIONI t, .,'� "—J AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTE'WED`USE f ,-TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS <br /> -I <br /> ❑ Industrial . d Open Bottom i ,❑ Manteca } "Dia of We11 Excavation ``` - Dia. i f Well Casing <br /> *`''"" -«�� Specifications <br /> 1 T e of Casin w Pe <br /> ❑ Domestic/Private C]'Gravel Pack �❑ Tracy '-r,, _ Yp Tg <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern 0 Surface Seal Installed by <br /> Repair Work Done ❑ Type of dump H.P. State Work Done <br /> 4 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') I <br /> Depth I Filler Material (Below�50'l r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION DESTRUCTION 71 (No septic system permitted if public sewer is <br /> I . available.within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> i SEPTIC TANK ❑ Type/Mfg Capacity �� No. Compartments <br /> PKG, TREATMENT PLT. ❑ ' I �' Method of Disposal <br /> Dist to rest: Weil Foundation U +� P e Line <br /> LEACHING ZINE ❑ No. Length"of.lin s Total length/size A <br /> FILTER BEDS ❑ Distance to nearest: Well Foundation Property Line <br /> � I r <br /> SEEPAGE PITS C) *Depth " Size Number t <br /> SUMPS '�„� Ell ,Distance to nearest: Well Foundation Property Line <br /> r 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, stateaaws, and <br /> rules and reguii-tions of the San Joaquin Local Health District. <br /> that in the performance of the work for which this permit is issued, I shall not <br /> Home owner�censed agent's signature certifies the following: "I certify <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 fallowing: '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 Cal-iforn'i-a." r <br /> The applicant ust call fo all re ins ons. Complete drawing on reverse <br /> 1' SignedLl Title: - Date: � i <br /> - f FOR DEPARTMENT USE ONLY <br /> I Application Accepted by �� �� n'•"""` Date <br /> — -�I< Area d 41 <br /> ` Date Final Inspection by Date f 6 �' <br /> Por Grout Inspection by , <br /> " Aditditional Comments: — � <br /> ❑ 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.O. Box 2009, Stll CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> +EH 1324(REV.1/BE) -� <br /> EH%28 Al <br />