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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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. f 4 <br /> Job Address L.3fi X �CtP7^' C City iv Lot Size O v PM <br /> Owner's Name 4 , Address Phone <br /> Contractor's Name _E_Zi9,_0_ 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. 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 D Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump ,k, H.P. State Work Done 51,y <br /> Well Destruction ❑ Well Diameter i Sealing Material Itop 501 vV <br /> Depth Filler Material (BeI2 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> availabie within 200 feet.) <br /> Installation will serve: Residence_/ Commercial_ Other i <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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 0 <br /> Distance to nearest: - Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearglVe Foundation Property Line <br /> SEEPAGE PITS FKDepth ?i1- Size 1. Pe Number <br /> SUMPS ❑ Distance to nearest: ' "'Well A11A <br /> /f' 'Foundation / �� Property Line. ld <br /> DISPOSAL PONDS ❑ JC61rier- && <br /> 1 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."• 7 <br /> The applicant must call for all squired inspec'ons. Complete drawing on everse side. <br /> Signed Title: Date: 3 <br /> FOR DEPARTMENT USE ONLY 11nn <br /> Application Accepted by DL Date ! ' Area LJ� <br /> Pit or Grout Inspection by Date Final Inspection by f Date [ <br /> Additional Comments: _ <br /> *_Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> App l-cant- Returnail copies to: Environmental Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEf I � <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> +EH 13.24{REV-40/83) US-u0 3-13-SS" R.!5--?"-o <br /> EH W28 !r <br /> I <br />