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1 <br /> APPLICATION FOR PERMIT '• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 5 <br /> 1601 E. HAZEL TON 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 /> Local Health District. w <br /> Job Address 4S<0'e,{ `~'^'� '`� k " City �*�c�+rw(p.._ Lot Size ��— PM <br /> F_ r <br /> Owner's Name <br /> AAddress _._ -:2d!;5 9S *VaLe/Sd Phone <br /> Contractor oeddclA <br /> Address. onel *4,.. 4 License No. s Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> El ❑ �� � <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR fNE W <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� �f_ <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of We Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ( ^ 4 <br /> V ' <br /> Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done „1 <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <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 /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ll 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 length/size � <br /> FILTER BED I] Distance to nearest: Well Foundation Property Line ) <br /> s <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> F 1 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 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 /> 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 fol re fired inspections. Complete drawing on reverse side. <br /> P e- <br /> Signed X Title: v Date: <br /> l FORNEPARTMENT USE ONLY I <br /> Application Accepted by Date + Area 12— <br /> T <br /> 2— / <br /> Pit-or Grout Inspection by Date Final Inspection by� �� _ <br /> Additional Comments: <br /> ❑ Stk 466$781 EJ Lodi 369-3621 C7 Manteca 873-7104 ❑ Tracy 835-6385 - <br /> { i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE .PERMIT"NO. <br /> + EH 13-241REV.i/a 5) <br /> EH 14,26 <br />