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� APPLICATION FOR PERMIT <br /> 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 - y <br /> 1601 E. HAZEL T ON 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 Rules and Regulations of the San Joaquin <br /> Local Health District. yr <br /> Job Address w.Ll City Lot Size �s�/ Z ) PM <br /> Owner's Name a �/ Address UZ e d2A iw C,t Phone <br /> Contractor's Name License No. QO Phone C✓5's <br /> TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 60"t'SEWER LINES DISPOSAL FLD._' ? PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �t <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation fFT Dia. of Well Casing <br /> j 6omestic/Private 111travei Pack ❑ Tracy Type of Casing—_ Pyel Specifications 1.2 , <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typ of Grout <br /> ❑ irrigation ---4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _n <br /> Well Destruction ❑ Well iameter S g Mate i (t�o�(50') '1• <br /> QGt/!~L.�t10 � ept ollF e�aterial {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is p <br /> 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 /> SEPTIC TANK ❑ 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 ❑ Distance to nearest: Well Foundation Property Line <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 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 ust call for all re u' inspections. C mplete drawing on reverse MIR? <br /> i <br /> Signed u f• Title:. Date: / <ZO V <br /> A FOR DEPA ENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by_. Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> * RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV. 10/83) �,.` 17.k7q 7�3/ i-I�bo f <br /> EH 1428 <br />