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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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,Ryles and Regulations of the San Joaquin <br /> k Local Health District. w <br /> Job Address �+ D��s�. P=A _,�. City eQNYt t ,,1Lot Size Q-IAc" PM <br /> Owner's Name Lo EAMPS-Address � � C2IN Phone <br /> Coftractor ` l irk Address <br /> laa��f-�� License lv0J_Eq.3&Z Phone 7-7q <br /> TYPE OF WELL/PUMP: WELL ,+ WELL,REPLACEMENT ❑ DESTRUCTION ❑ p- <br /> PUMP INSTALLATION.. -4- . -,SYSTEM REPAIR ❑—.-- ., .,,.OTHER ❑,.w w.:, . _ <br /> DISTANCE TO NEAREST: SEPTIC TANK ._ 9 SEWER LINES DISPOSAL FLD. PROP. LINEa�_ e <br /> FOUNDATION WELL OTHER WELLnor- PITS/SUMPS ' <br /> , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i I o Industrial _ *Open Bottom ❑ Manteca Dia. of Well Excavation 1 r <br /> Dia. of Well Casing l . <br /> V'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f� Specifications <br /> ❑ Public ❑ Other 11 Delta --��- -De th of Grout-Seale-- ypg {fGrout -5 <br /> ❑ Irrigation •w_4pprox. Depth Eastern Surface Seal Installed by V <br /> Repair Work Done ❑ Type of Pump -,� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-3 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I r!t 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 /> f (SEPTIC TANK ElType/Mfg Capacity .. - No.Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> q <br /> Distance to nearest: Well. Foundation 1. Property Line v <br /> LEACHING LINE ❑ No. & Length of lines - - -Tot I length/size '-- <br /> ;FILTER BED ❑ Distance to nearest: Well Foundation n Property Line <br /> ♦SEEPAGE PITS ❑ Depth Size {� Number' <br /> SUMPS 6,, ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I r r+„ IA 1 I I <br /> I hefeby 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 /> g 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 j <br /> 1 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." <br /> F The applicant must call for all required inspections. Complete drawing on reverse Sid , <br /> r Signed Title: ��° Date: <br /> FOR DEPARTMENT USE ONLY d <br /> !Application Accepted by Date <br /> ��y� _,__�oArea <br /> Pit or <br /> Grout spection by Date Final Inspection by �J G/' v7 ate <br /> Additional Comments: P.Ci� Gtr!-c�J d <br /> Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave., P.O. Box 2009 tk., A 95201 <br /> ' <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK , <br /> INFO CASH - RECEIVED BY DATE PERMWN0. r �'/ <br /> �S G���i ✓ <br /> + EH 13-24(REV.1/85) �57 <br /> EH 1428 <br />