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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i 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. '4ji7 <br /> Job Address Lot Size PM <br /> i Owner's Name 0Address L� ae� - � Phone <br /> Contractorti@�'J Address i ilL�License No 15-11 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ y'SYSTEM REPAIR 0' OTHER ❑ <br /> DISTANCE TO-NEAREST:-SEPTIC TANK - SEWER LINES i DISPOSAL FLD. PROP. LINE --- -- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> N <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LYDomestic/Private ❑ Gravel Pack+ El Tracy Type of Casing Specifications <br /> El Public f_1 Other `{ ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth Eastern Surface Seal Installed by J <br /> Repair Work Done e Type of Pump--A AW H.P._ State Work Done - <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ___Z j <br />' ," r �s available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other [' <br /> Number of living units: —\Number of bedrooms k c <br /> Character of soil to a depth of 3kfeet: I tis Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments 0 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ,Well Foundation : •�'.,�,rbperty_Line t <br /> LEACHING LINE ❑ No! <br /> & Length of lines j Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ DepthY I Size Number <br /> _=SUMPS - -- W❑•-Distance-to-nearest:-wWell� �Foundation- ._-� Property-Line <br /> DISPOSAL PONDS ❑ i'" t <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 J6aquin 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 n <br /> certifies the following:"I certify that.irrthe 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 n2ust gall f required inspections. Complete drawing on pavIrse side. _ �,•rt <br /> s <br /> Signed Title:sl <br /> Da#e: ' <br /> FOR-'DEPARTMENT USE ONLY <br /> =1 I - 'ti) <br /> Application Accepted by D t `Z «a '.Area <br /> Pit or Grout Inspection by Al Date jg*@Llnspectlon `jDate 7t, � <br /> O <br /> Additional Comments. O Ul O a 3 <br /> ❑ Stk 466-6781 Lodi 369-3621 -" nteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Re;urp all cppies tD: Environmental Healt Per /Services 1601 E. H elton Aye <br /> es OL. Box tk., CA 952D1_­ <br /> C4-. <br /> .^"^ I . <br /> C -. un 7� S' V151 <br /> 5 r'� <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> + EH 13-24{REV. <br /> EH 1426 <br />