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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CAv- <br /> Telephone (209) 466-6781, k d J r 4 o w k <br /> PERMIT EXPIRES TYEAR 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 <br /> . —� / fl e- <br /> J• City n,`Lit Size PM <br /> j),Owner's Name BOLL XhIlts-ori Address ��� l��r-k�/�..�_.__ .� Phone 1-44 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑. _ _ WELL REPLACEMENT-❑ DESTRUCTION ❑r <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 `r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f-I Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I 1 Irrigation --Approx. Depth I I 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 f;1 REPAIR/ADDITION l 1 DESTRUCTION- Mo septic system permitted if public sewer is <br /> ' vailable within;200 feet.) <br /> Installation will serve: Residence Commercial Other " 1 <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. ❑ # Method of Disposal <br /> Distance to nearest: Well I Foundation Property Line i <br />'i LEACHING LINE ❑ No. & Ifength of lines Total length/size <br /> FILTER BED © Distance to nearest: Well I Foundation Property Line ; <br /> i t t <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ k <br /> F <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, I 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." i <br /> Thea applicant must call f all re r Y.. <br /> pp q inspection 'Complete drawing on reverse side. � »- <br /> x Signed X Title: Date: "i I-greL <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedby Date Area <br /> Pit or Grout Inspectio Date Final Inspection by �r �i Dated 1' <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> r EH13-24(REV.-+/n5) �+,,;1 <br /> EH 14-26 I-L-Ke a<) I <br /> i <br />