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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. h , _ ) <br /> City 1545 AL.6�Lot Size- �� PM <br /> Job Address <br /> Owner's Name Address Phone <br /> Contractor� UGG Address License No. 4V6_;r?FA1Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ,WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t 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 V <br /> lIr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications v <br /> [-I Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout +� <br /> i I Irrigation _ _Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done L7 Type of rPump�_. H:P. State Work Done <br /> Well Destruction ❑ Well Diameter --Sealing Material (top 501 <br /> Depth <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION>( DESTRUCTION I 1 Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other y } <br /> Number of living units: —4— Number of bedrooms- 12 r <br /> Character of soil to a depth of 3 feet: SAID�/X CZA -Water table delth ` <br /> SEPTIC TANK ❑ Type/Mfg capacity `F No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation `Property,Line` <br /> LEACHING LINENo. & Length of lines �4_ � 'r Total length/size <br /> e i <br /> FILTER BED ❑ Distance to nea'rest: .r Well *a--!!!r Foundation Property Line! I <br />[ SEEPAGE PITS 11 Depth j > - Sizer I 'Number <br /> r SUMPS El Distance to.nearest: WeN. 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 cougty ordinances,''state-laws;.and <br /> rules and regulations of the San Joaquin Local Health District. f � �._ k , <br /> I Home owner or licensed agent's signature certifies the following: "I certify that in the performance- of the!%ibrk_far,-whiiNthis permit is.issued, 1'shall not <br /> employ any person in such manner as became subject to workman's compensation laws of California." Contractor's hiringeor 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 gersons'subOct to;workman's compensa- <br /> tion laws of California." ti jf <br /> The applicant must call for all equir d inspections. Complete drawing on reverse-side. <br /> 3 r <br /> ✓. <br /> I Signed X.- / , Title: <br /> r OR DEPARTMENT USE ONLY <br /> t <br /> I Application Accepted by " Date Area <br /> ig 5147 <br /> 4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> t t <br /> Additional Comments: I <br /> _0 Stk_466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 <br /> Applicant - Return-all"copies to:-Environmental-Health Permit/Sennces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYs _. DATE � PERMIT No. <br /> INFO <br /> « + EH 13-24(REV.I/H 5) �� �}Q — r P7r <br /> EH 14-28 <br />