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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> l (} <br /> telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,t (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 Sart Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address1h I Rd City Lot Size PM <br /> i Owner's Name 1 a )elf y Address �a 11 c�j a L!❑t1 Q�t LQ�7' Phone [ <br /> y '0 <br /> Contractor i Address rR-� License Not , _Phone r0 <br /> TYPE OF WELL/PUMP: W WELL ❑ WELL REPLACEMENT A DESTRUCTION'X <br /> PUMP INSTALLATION 34 SYSTEM REPAIR ❑ OTHER 0 <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK �[� SEWER LINES DISPOSAL FLD. d PROP. LINE � <br /> FOUNDATION AGRICULTURE WELL.—- OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation : Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> --,-Type-of Casing Specifications /! <br /> 1-1 Public F1 Other ❑ Delta Depth of Grout Seal Type f Grout <br /> I Pirrigation .- ..p�31P..Approx..Depthy--- I I-Eastern_. ; rface Seal Instakled by <br /> Repair Work Done ❑ Type of Pump 3[2-k— H.P. State Work Done <br /> Well Destruction Well Diameter �.._._,_.._ Sealing Material [top 7t�T r <br /> Depth A:R0 r Filler Material (Below'Sr0'I� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence Commercial_ Other. <br /> Number of living units: Number of bedrooms <br /> .- ' <br /> Character of Sail to a depth-of.3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ^p P _ { Method of Disposal <br /> Distance to nearest: Well Foundation^� Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> FILTER <br /> ength/sizeFILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> F SEEPAGE PITS 11 Depth I Size _ Number <br /> SUMPS 0 Distance to nearest: Well Foundation t 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 lavers, and <br /> f rules and regulations of the San Joaquin Local Health Diatrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perfognLL ce 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." •- e <br /> The applicant must call for all required inspections. Complete drawingtonMre�erse side. <br /> Signed <br /> C��N����. Title: <,e_,e ,ee Date: 5 t <br /> --- r - _€fzARTMENT USE ONLY : <br /> Application Accepted by _ A Date / Area _ <br /> Pit arOld <br /> t Inspectio Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 0 Manteca 823-7104 ❑ Tray-835-6385 to- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009,`` / Stk., CA 1 <br /> ' FEE ' AMOUNT DUE AMOUNT RE ITTED CK RECEIVED BY DATE PERMIT'NO. <br /> s INFO CASH _ �. <br /> t r`' <br /> +.EH 13-24(REV. <br /> Xf ?� <br /> EH 14-2e <br />