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APPLICATION FOR PERMIT .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ` PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED <br /> (Complete in Triplicate} <br /> k <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. A/c„ G - <br /> ,// ,�e�� j� ,.wry� <br /> Job Address ��d ��r � " "� City Lot Size —400- <br /> A <br /> . 00- PM t <br /> A. " ��efS/dam &4!!2e <br /> �// <br /> Owner's Name Address �� ny &i &4!! Phone <br /> ell <br /> e,I�4 I.� ` <br /> Contractor's Name W License No. <br /> TYPE OF WELL/PUMP: NEW WELL�K WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION'S SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK lS�dV44 SEWER LINES �-S�DISPOSAL FLD�� PROP. LINE <br /> FOUNDATION �0,� AGRICULTURE WELL OTHER WELL S PITS/SUMPS/&AJC <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation i.-? Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack LITracy Type of Casing Specifications <br /> �❑ Public ❑ Other ❑ Delta Depth of Grout Se Type of Grou <br /> ❑ Irrigation --Approx. Depth- ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Hq3. State Work'Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 f <br /> Depth Filler Material (Below 501 <br /> TY; F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - <br /> ,availabie within 200 feet.) v+� <br /> Installation wills Residence_ Commercial_ Other_ j S •� <br /> Number of living units: ber of bedrooms Q <br /> Character of soil to a depth of 3 feet: Water table depth I l <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ation sProperty Line <br /> LEACHING LINE ❑ No. & Length of lines o ngth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prop ine <br /> I <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Line <br /> ` DISPOSAL PONDS 71 <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, a <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, l 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 requi d inspections. Comple a drawing on reverse side. <br /> Signed Title: 4�!6 Date: x5 <br /> 1 <br /> FOR DEPARTM NT USE ONLY <br /> Application Accepted by v ` Date Area <br /> Pit o rou Inspection by date ' Final Inspection by ate <br /> Additional Comments: - <br /> ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all c s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> + EH13.24[REV.10lR3I ` Z5-1 I <br /> EH 1428 `� 1 �.�• ��s �! S �10 y� <br />