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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 forwell/pu p as d the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ►���fff{ <br /> ZY <br /> Job Address l -1� ��� �Nr City Lot Size PM <br /> Owner's Na <br /> v/ �' , 4ddress" O �re, «} Pf1on k2 // <br /> V11• <br /> xw �.._,.-�=Gonttaetor _Address- --.­l1~-m-4-"_„'_-"..�-Llcense <br /> TYPE OF WELL/PUMP: I NEW WELL ❑ WELZREC EMENT D DESTRUCTION ❑ <br /> 1PUMP INSTALLATION ❑' REPAIR ❑ OTHER. ❑ <br /> DISTANGE T,O NEAREST:xSEPTIC TANK Pk ER LINEDISPOSAL FLD. PROP. LINE <br /> FOUNDATION' AG GULTU OTHER WELL '� � ':PITS/SUMPS <br /> 11VTENDE6 USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial II� ❑""Open Bottom—_,,,Cl Manteca Dia. of Well Excavation. Dia. of Well Casing <br /> O Domestic/'Private ❑ Gravel Pack D Tf.a yf Type of Casing Specifications <br /> ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal i Type of Grout <br /> ❑ Irrigation f __--Approx. Depth- ❑ East rface Seal Installed bye —�- <br /> Repair Wark� one. Type of Pump H.P. State Work Done <br /> Well Destruction 'I]'" Well Diameter "`' Sealing Mater( (top 50'Ir <br /> Depth Filler Material (Below 501 F t' x ,R F,_ 1 / <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cr REPAIR/ADDITION ❑ DESTRUCTIONS[ (No septic system permitted if public sewer is ; <br /> ,--available within 200 feet.) <br /> i InstallatiJ will serve: Residence Allll Commercial_ Other <br /> 'Number ofphpliving units: T-77--Number of bedrooms' <br /> Character of soil to a depth of 3 feet: Water tabledepth <br /> SEPTIC TANK ❑ Type/Mfg rl KAA& Capacity No. Compartments <br /> OKG. TREATMENT PLT. ❑ 1 Method of Dispo - + <br /> ' Distance to nearest:"k Well Foundation /0 <br /> Property Line <br /> i <br /> TEACHING LUNE ❑ No. & Length of lines To length/size ' <br /> I FILTER BE61 ❑ Distance to nearest: Well dation LIAUA erty Line <br /> JW <br /> i <br /> SEEPAGE PIh. <br /> TS '❑ Depth" Size Number <br /> IllSUMPS Il: ❑ distance to nearest: We Fou wK Property Line �l <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'fallowing: "I certify that in the performance of the work for which this permit is issued, 1 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 /> � <br /> certifies the following:"I certify that in the perfo ante of th`e work`f*or-which this,permif is"issued,"I shall-employ'p_ers�ns subject to workman's.comperisa- , <br /> tion laws of� alit ia." i <br /> The applicant caIIjrj1q 'ed i ions. "Complete drawing on reverse side. \(meq <br /> 0r �./ <br /> Signed Title: �, Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Are zC <br /> 4 d -�' <br /> Pit or Grout Inspection by Date Final Inspection by Date / ! <br /> Additional Comments: t <br /> ❑ Stk 46&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 /> a <br /> F I FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> BY DATE PERMIT`NO. <br /> INFO <br /> + EH 13-241REV.1/8151 D Yr'�.- <br /> EH W28 <br /> r <br />