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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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. ��yy <br /> Job Address f G <br /> M 1�� + _ city C Lot Size 'C� �" PM <br /> Owner's Name Address �� i� Phone <br /> Contractor i �aZ l7Address �d ;/- A417dA License No. Phone <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 /> ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications <br /> M Public F Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __.Approx. Depth l 1 Eastern Surface Seal Installed by V <br /> Repair Work Done ❑' Type of Pump H.P. State.-Work Done, <br /> Well Destruction ❑ Well Diameter Seating Material (top 50'1 <br /> Depth ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I,1 DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> T " -lnstaltatioli will-serdd: -Residence' Y Commercial--- Other- <br /> Number of living units: 4-- Number of bedrooms, <br /> ,. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK I --Type/Mfg . Capacity No. Compartments <br /> PKG. TREATMENT PLT. Method of Disposal <br /> Distance to nearest: Well Foundation- Property Line-/ �oc <br /> LEACHING LINE No. & Length of lines1 �Q�T Total length/size dT <br /> FILTER BED ❑ Distance to nearest: Well A:K Foundation -2Or—T Property Line CLOr7 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: W0 Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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." <br /> The applicant must call for II required inspections. Complete drawing on reverse side. <br /> Signed X__a_1X141 Title: A­r1-L� -- fQ�j�jf <br /> Date: _ <br /> R DEPARTMENT USE ONLY '`' <br /> Application Accepted by 5 7 <br /> Date Area <br /> D <br /> Pit or Grout Inspection by Date Final Inspection by Date dl :d <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 A-M/OUNT REMITTED CA 5H RECEIVED BY _ DATE �PEyR�MIT N�yO./� <br /> +.EH 13'24{DEV.w/x 51 �,�0 //� �_ _ � OF <br /> 111•l <br />