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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �� 1601 E. HAZELTON AVE., STOCKTON, CA <br /> q/ Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San JoaquinLocalHealth 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 forylweellll/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. n"'v_" _IQr <br /> Job Address ,F��1 E i�,t Lot Size PM <br /> Owner's Name Rt3 POLO" Address \a B&A 385 V,,, `k'__ Phone <br /> Contract _ W Address `rQ y`�r^�` License No. Z 0 Z Z Phone .369'– 0S <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 /> FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —_.Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repair Work Done LJ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth r Material (Below 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l(REPAIRYADDITION K DESTRUCTION <br /> � I I (No septic system permitted if public sewer is <br /> to( w .�� <br /> availab thin 200 feet „ <br /> Installation will serve: Residence_ Commercial V Other__ V (� tJ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <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 1` Foundation Property Line <br /> It <br /> SEEPAGE PITS �,Q Depth S Size "1 Number <br /> SUMPS Ll Distance to nearest: Well.J.&O Foundation_Q Property Line—'113, <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 applican st call for I re ired inspections. Complete drawing on reverse\Slid <br /> 2 Q <br /> Signed X Title: ' e Date: J `' <br /> FOR DEPARTMENT USE ONLY Z <br /> Application Accepted by Date Z—% ✓ Area <br /> or Grout Inspection by� ate Final Inspection by _ Date <br /> O <br /> Additional Comments: <br /> ❑ Stk 466-6781 O 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, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CAS RECEIVED BY DATE PERMIT'NO. <br /> INFO ! (/��] <br /> +.EH 13-241REV.1i851 �� � <br /> EH 14-26 J c7LJ <br />