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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-11 YEAR FROM DATE-ISSUED <br /> (Complete in Triplicate) j <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. �. <br /> Job Address 2 053D <br /> City Lot Size—1 PM <br /> Owner's Name k,-Q- Address 0 Phone <br /> .�E no <br /> b1�1- N If II • �� bn1 License No. Phone. <br /> —Contractor ddress <br /> TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO WNEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ElIndustrial 11Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> El Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx.•Depth ❑ Eastern Surface Seal Installed by vtJ <br /> r - <br /> Repair Work Done ElType of Pump _.. �,— H.P. State Wo D e G <br /> Well DestructionWell Diameter Sealing Material (top 50'1 <br /> XDepth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> E k Installation will serve: Residence Commercial_ .Other <br /> Number of living units: Number of`bedrooms <br /> Character of soil to a depth of 3 feet-1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg,, Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ '-Method of Disposal <br /> Distance to nearest: Weil Foundation ' Property Line <br /> LEACHING LINE _ ;d❑- No. & Length of lines { Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number S x^ N <br /> SUMPS ❑ Distance to nearest: Well Foundation .Property Line <br /> a <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 regula"tions of the San Joaquin Local Health District. X V. ,Y <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 Califomia." 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 applica all for all re ' -faspections. Complete drawing on reverse side. <br /> Signed <br /> r Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> It o <br /> Application Accepted by 1 Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 8354M <br /> Applicant- Return all copies to: Enviroinmentai Health Permit/Services 1601 E. Hazelton Ave.,'P.O. Box 2009,'Stk., CA 95201 <br /> I IL FEE <br /> kMO,�NTDUE AMOUNT REMITTED' CK MM9RECEIVED BY DATE PERMIT NO. <br /> + EH13-24inEv.1/051 <br /> EH 14-26 . <br /> i <br />