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APPLICATION FOR PERMITu <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA ["0 <br /> f <br /> Telephone {209) 466-6781 QV Jr- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN 1984 <br /> {Complete in Triplicate) kP,4�1` IV too, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descnblPwg�gtlon 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 8 Joaquin <br /> Local Health District. <br /> Joh Address ' �' Nu`{"+ 3.3 '� A14�'� �' ��`���� City._���-�_._._.. Lot Size PM_ <br /> Owner's Name z � Address Phone" J 7� <br /> Contractor's Name ��"`^ License No. , i PhoneT� <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 ❑ Delta Depth of Grout Seal Type of Grout <br /> Ir?frrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Q' Type of Pump k.P. ? —I-- State Work Donja�. <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AEPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_-,,Commercial_ Other <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 <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 Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <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 oertifies 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."Contractors 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 rift Il for all 5-$4 ed inspections. Complete^draj�wing on`reverse side. J <br /> Signed X "�J � fitle: ""� ��� _� Date: �/ �" <br /> � Fd DEPARTMENT USE ONLY <br /> Application Accepted by 4 Data �— Area +� 7 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional 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, Stk., CA 95201 <br /> CK <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED :CASH RECEIVED BY DATE r PERMIT"N0. <br /> + EH 13-24[REV.10/83] <br /> EH 1428 7 <br />