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APPLICATION,.FOR PERMIT <br /> f _ <br /> SAN JOAQUIN LOCALHEALTH DISTRICT <br /> i <br /> 1601 E. HAZELTON AVE.;.STOCKTON, CA <br /> Telephone (209) 466-6781 ,. <br /> PERMIT EXPIRES 1.YEAR FROM DATE ISSUED <br /> iComplete 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. *I�r <br /> Job Address ITftA�4]� 1 � _ � ��Ci City 5 Lot Size PM <br /> Owner's Name E� h4 � dress 94n2a <br /> QS a,1�d t, Phone <br /> r, Contractor. 19d=4 Address License No. Phone <br /> T OF WELL/PUMIV. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA COWST TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 50') j ; <br /> VQ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> _ 4- available within 200 feet.) <br /> Installation will serve: Residence. Commercials 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 f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line <br /> ,may, <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 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 shalt 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." <br /> The applicant must call for all a fired inspections. Complete drawing on reverse side. ,Q <br /> Signed Title: Date: <br /> 74 MEIPARTMENT <br /> USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comment <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 Manteca 8*7104 ❑ Tracy 835-6385 / , J�7 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 01` 1 I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-24(REV.1/6 5) <br /> ` EH 14-26 Y V Cj ✓�� <br />