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( APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 3 Telephone (209) 466-6* <br /> PERMIT EXPIRES I YEAR°FROM DATE ISSUED' <br /> r (Cornplete in Triplicate) �r <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. qrr <br /> Job Address <br /> City Lot Size PM <br /> Owner's Name D.C,z ^+.t%t� -'��Ie�Y►u7. .Address 19 f., _ <br /> Phone <br /> � r <br /> Contractor 7,n4=46164—ll <br /> C­ <br /> ContractorAddressr <br /> License No�6_ '3�/��-- Piton � /�C�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />' <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications h! <br /> ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout f <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump d_c4_(/— H.P. Jam_- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material {Below 501 <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 /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg { Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ j <br /> A 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. - 5 Property Line <br /> SEEPAGE PITS ❑ "t'Depth - Size <br /> Number <br /> SUMPS ❑ _ Distance tot nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11 <br /> I hereby certify that I have prepared this application and that a w-bfk-will-be•done-in-accordance-with-San--joequin.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 ' <br /> " ha� _ 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 coirpensation 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 /> nThe applicant must all for all d inspections. Complete drawing on reverse side. r <br /> Signed X Title:. Dater ^�'7 <br /> OR DEPARTMENT USE ONLY <br /> �] <br /> Application Accepted by Date Area <br /> Pit or Grout'lns ction b <br /> pe Y Date Final Inspection by Date <br /> i <br /> Additional Comments: "- <br /> ❑ Stk 466-6781 ❑ 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 /> FEE INFO' MOUNT DUE - AMOUNT REMITTED CK*CASH RECEIVED BY DATE PERMIT"NO. I <br /> +EH 13241AEV.7/651 c - <br /> I <br /> EH 14-26 �sl. �i i <br />