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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 0172 5 /9C <br /> City C.� Lot Size �! PM r <br /> Owner's Name s — <br /> +Address Phone <br /> Contractor AL FE Address rJd T 41 <br /> License No.A26"5F—;LPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> EWER 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 <br /> 11Domestic/Private ElGravel Pack L1TracyTracy Type of Casing , Dia. f Well Casing <br /> LlPublic _ <br /> ❑ Other El Delta! Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depths ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material Itop 501 <br /> Depth I-Filler Material (Below 50') `v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIWADDLTION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is `\�3 <br /> �. available within 200 feet.) <br /> Installation will serve: Residence Commercial Qther <br /> Number-6f living units: -Number of bedrooms <br /> Character of soil to a depth of 3 feet: a <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �' .r✓ Capacity__ c�arx� No. Compartments <br /> PKG. TREATMENT PLT. ❑ W <br /> Method of Disposal <br /> Distance to nearest: - Well <br /> d� _ Foundation�6! Property Line_���_� ✓ <br /> LEACHING LINE LJ No. & Length of lines ~aX !!!'D Total length/size alta 12— <br /> Q ip ' <br /> FILTER BED ❑ ±Distpo Barest: �We J�Fif" Found ion Prop�rty Line <br /> SEEPAGE PITS ❑ DepNumber <br /> SUMPS ❑ 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 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 /> The applicant must call for al re d inspections. Complete drawing on reverse`side. i <br /> Signed XTitle: ' �Q — <br /> r <br /> Date: <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by ` Date / <br /> �`a Area Q <br /> Pit or Grout Inspection by Date Final Inspection by 7 <br /> Date <br /> Additional Comments: kZ&4 dLLrA 'Cr <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. ox 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT•NO. <br /> + EH14-26-24(REV.tin5) <br /> EH 14 r7-1V-Sb 'Rra-1-7b <br />