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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 heieby 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. <br /> { I <br /> Job Address `'' "" i + City Lot Size00k&Q,� PM <br /> T P `i-. � <br /> Owner's Nam Address O IJ Phone <br /> �.r T � / <br /> r Address T:v�Mc U� E License No. Z 'Z(R Phone <br /> Contract <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.WEL'L `°OTHER,WELL ^f' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ' ❑ Open Bottom --- ❑ Manteca- F Dia. of Well Excavation Dia. of Well Casing <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`7 Public 1 f] Other ❑ Delta Depth of Grout Seal Type of Grout <br /> --- <br /> -1 ] Irrigation _.Approx!Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ �• <br /> Well Destruction Q Well Diameter Sealing Material Itop 501 <br /> Depth I er Material {Below 50') <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I] IR EPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> � <br /> x 'within 200 feet.) <br /> Installation will serve: Residence' Commercial Other <br /> Number of living units:' Number of bed, oms <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 Foundation Property Line <br /> LEACHING LINE r❑ No. & Length of lines Total length/size <br /> FILTER BED j.❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS l I Depth I Size xNumber <br /> SUMPS Distance to nearest: Well 0c) Foundation %0 Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sarti 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:2 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."' Ir , <br /> The applicant ust all fo II re wired inspections. Complete drawing on re*v�e a de. q <br /> Signed X Title: V. f Date: <br /> r .- ' ' *ter , <br /> I FOR DEPARTMENT USE ONLY'VL­ ' <br /> Application Accepted try _ y ' r Data t ` Area <br /> Pit or Grout Inspection by Date Final Inspection by��f►�Q� Date <br /> 1 <br /> "Ii <br /> I <br /> Additional Comments: 6rO✓,,j ct:&Q$er at ! e _<4Qa fnjL . —6- �s 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 R-ef,-,1r­ -o(-- to - 60 be''r <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 C'WJC^e` 6-{c�i S 4rC*-_k <br /> 1q Za <br /> FEE CK 0 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13-24(REV.t/n5) 00 <br /> EH 14-2a II 176--V9•ate 1 C <br />