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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT • <br /> 1601 E. HAZE 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 hareby 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. �] �y <br /> Job Address r 0 t rM.,n d�Pt cw;ty PM <br /> e I <br /> Owner's Name _C1Z�j ress Jhone R " <br /> V tr �VV <br /> cs7Z <br /> Contractor Address a q--Z.7 License No.IbZ37�Phone <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 LIQ <br /> ❑ Ind�strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f Well Casing <br /> [�T'Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications d <br /> Cl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> —_— <br /> I I Irrigation —.Approx. Depths�I_i astern Surface Seal installed by - <br /> Repair Work Done C�Type of Puml H.P. —.1 State Work Done 'i dr 014 Q <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50'I — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 (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 lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 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 regu ations of the San Joaquin Local Health District. <br /> Homr:owner c 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 an arson in su h manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t e f Ilowing: " certify that in the perform nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law of alifc <br /> The ap lican ca r all r c' S. mpiete drawing on r ver a side. ? <br /> Signed Title: Data: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 457 <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Z <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 /> FEE AMOUNT DUE AMO NT REMITTED Cy CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +,EH 13-24(REV.I/n 5) <br /> EH 14-2a <br />