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r APPLICATION FOR PERMIT `00 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ..r (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 /> r Local Health District. u <br /> Job Address t. 1 Nle`� q City Lot Size 1 r, � PM <br /> Owner's Name VWc-'Address i lv 'q q 14 <br /> `^' ` a&A4�OPhone <br /> Contract <br /> W Address'l.k-11 I License Nolzy zZ(- Phone6��� (US <br /> r. TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT D DESTRUCTION D <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 /> r.. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('i Public <br /> D Other F1 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 LJ Type of Pump H.P. State Work Done <br /> No Well Destruction D Well Diameter Sealing Material (top 501 <br /> Depth iter Material (Below 501 -- r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIR ADDITION DESTRUCTION <br /> within 200 feet.) <br /> ION I I (No septic system permitted if public sewer is ^ <br /> (}b�j <br /> Installation will serve: Residence_ Commercial /X Other, � / r-- <br /> Number of living units: Number% edroom -1--- <br /> Character of soil to a depth of 3 feet: \ ^n Water table depth <br /> r.. SEPTIC TANK ❑ Type/Mfg " ! Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> size C_r <br /> th/ <br /> len , <br /> LEACHING LINE t1 No. & Length of lines — Total g V <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> If <br /> yt Depth r _ Nrumber <br /> SEEPAGE PITS (� <br /> SUMPS LI Distance to nearest: Well ►tin Foundation Property Line!XS t <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 county ordinances, state laws, and <br /> ftorules 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 call for a r ui d inspections. Complete drawing on reverse side. +, <br /> P <br /> Signed X -�-� Title: --\), Date: C`0 <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Dab�y <br /> - Area <br /> rar or Grout Inspection by atel r Final Inspection Data <br /> L' <br /> Additional Comments: <br /> O Stk 466-6781 D 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 MOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT'NO- <br /> INFO <br /> EH 13-24{REV. <br /> EH 14.26 <br />