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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! _ <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Is3Qxa.v� <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> •C�'/jf Al. GIInI.DSae City as eW Lot Size PM <br /> Job Address _ I d <br /> Phone 4d4 -05a <br /> Owner's Name <br /> , /� ([,/JVQrd�S Address 5/ <br /> Contractor Address 5 1f1� License No. Phone <br /> TYPE OF WELL/PUMP:. „ NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> CI <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. <br /> _ FOUNDATION AGRICULTURE WELL OTHER WELL SISUMPS i G <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT <br /> fl Industrial 1711 Open Bottom ❑ Manteca Dia. of Well Exca Dia. of Well Casing <br /> r. Specifications' » <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty sing - <br /> ❑ Public ❑ Other is,Deli Depth of Grout Seal Type of Grout <br /> I Irrigation _.-Approx Eastern Surface Seal Installed by <br /> s Repair Work Done a of Pump H.P. State Work Done <br /> Well Des n ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material Melow 50') <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION IJ REPAIR/.ADDITION t l OESTRUCTION .I.No septic system permitted if public sewer is <br /> available within 200 feet./ <br /> i <br /> Installation will serve: Residence_ Commercial Other i <br /> Number of living units: 1 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table di epth <br /> SEPTIC TANK EI Type/Mfg `Capacity No. Compartments <br /> PKG.,TREATMENT PLT. ❑ IL 2. Method of Disposal <br /> Distance to nearest: Well Foundation Property line <br /> i <br /> i <br /> h/ <br /> lengtsze <br /> I <br /> LEACHING LINE ❑ No, & Length of lines Total � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 <br /> SEEPAGE PITS l I Depth Size Number <br /> I ! <br /> t SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> S _ <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 /> I 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." t � <br /> The applicant must call for all required inspections.-Complete drawing-on reverse side.--^--- --- - <br /> Signed Title: <br /> Date: S`ao -F7 ..�_ <br /> A=== <br /> Y es <br /> Application Accepted by Date �� L,+� Area — <br /> Pit or Grout Inspectio y Date Final Inspection by .Date <br /> Additional Comments <br /> ❑ Stk 466-6781 fl Lodi 369-3621 ❑ Manta 623-7104 ❑ Tracy 835 6385 T <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 CASH RECEIVED BY DATE PER NO. <br /> INFO ' <br /> +.EH 13-24{REV.1/H51 SIJ� _ ��• 's� 0�7 v � r10 <br /> EH 14-29 <br />