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APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZEL 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. <br /> Job Address S 7 City Lot Size 573 PM <br /> Owner's Name W� ' 'l��� r Address Phone ,,70,�F f3 <br /> — - <br /> Contractor Address License-No, p J g z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO,NEAREST: SEPTIC TANK., SEWER-LINES _DISPOSAL-FLD. PROP. LINE <br /> 433 FbUNDATION AGRICULTURE WELL OTHER WELL - PITSISUMPS <br /> k I F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />'r ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private t ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> it Public Ll Other 71 Delta Depth of Grout Seal Type of Grout-- <br /> I I Irrigation �.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Re air Work Done ❑ Type f Pum ! 1 <br /> p { yp o p H.P. State Work Done <br /> Well Destruction El Well Diameter r Sealing_Material (top 507 <br /> Depth „ Filler Maferial=(Below 50') �- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( RE AI / <br /> P R ADDITIOfjI_l,l DESTRUCTION l I INo septic system permitted ifp ublic sewer is- <br /> Z yi available within 200 feel.) <br /> Installation will serve: Residence Commercial_ Other ~j <br /> Number of E!ving uni Ps: Number of bedrooms' i I I <br /> t <br /> Character of sod to a,.depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity = No. Compartments 2, 1 <br /> PKG. TREATMENT PCT..❑ _ Method of Dispose <br /> Distance'to nearest: WeII�ts.� Foundation/�!157 _.L Property Line <br /> LEACHING LINE E•E r❑ : No. & Length of lines [-� f -- Total length/size {� <br /> FILTER BED ❑ Distance to nearest: Well 00 Foundation Property Line <br /> i s I <br /> SEEPAGE PITS r I I ' Depth i Size Number (- <br /> SUMPS i Ll Distance lto-nearest:­- Wel! - -Foundation - -- M Property Line t <br /> DISPOSAL 1`0M1I1DS l ❑ <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 DiMrict. . I <br /> Home owner or licensed agerit's signature certifies the following: '.l 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: 'II carti'fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law o rota." <br /> • TheYapplicant t call for all e 'ed 'nspectio'S. ete drawing on v e side. <br /> Signed X Title: Daae: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by Dace Area <br /> Pit or grout lnspection?by ` Date% Final Inspection by Z4114 Date 15,0 <br /> Additional Comment's:,' y _ <br /> O Silk 466-6781 #O-Lodi-369-315211---0 Manteca--823-7}04--.-. R-Tracy°.-1335.6385 v-- - --� <br /> Applicant - Return all copies to:-Environmental-Health-Permit/ServiW� 1601,,E.--Hazelton-Ave--,-P:O:Box-2009;Stk.; CA1`�01 <br /> FEE AMOUNT DUE AMOUNT REMITTED " CK RECEIVED BY DATE PERMITNO. <br /> INFO' CASHj}/�/ <br /> .+.EH 13-24 I REV.i i H 5E U Jif �� U/ <br /> EH 11-26 ti <br />