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FOR PERMIT <br /> TION <br /> SAN JOAQUINALOCAL HEALTH D STSCIO S <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> s Telephone (209) 4666781 <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. <br /> Job Address City 4144CAL72f I�' Lot Size 1) y( t .10 PM <br /> Owner's NameZQ- Address c'd Q# Phone G y'/ C! <br /> Contractor 15564011Address License No. Phone goK IhYi r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TOTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDAT AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR TRUCTION SPECIFICATIONS " <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well x Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 77 Type t <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,W DESTRUCTION X (No septic system permitted it public sewer is <br /> ��.. available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedroo <br /> Character of soil to a depth of 3 feet: &4 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 /> i <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, 1 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 for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: 2 –25 ,2 <br /> 4v e <br /> FOR DEPARTMENT USE ONLY <br /> _2"Application Accepted by Date Z Area <br /> 41/ <br /> Pit or Grout Inspection by Date Final Inspection by ate <br /> VV 7t <br /> Additional Comments: -- } <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ M nteca 823-7104 YTracy 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. <br /> + EH 13-241REV.r/a5) -] <br /> EH 1426 �^5�R <br />