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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) 466-6781FILE <br /> PERMIT EXPIRES 'f'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <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 /> C Local Health District.. <br /> Job Address . <br /> ��,� �1l � City `1 5l`9 <br /> Loi Size �� PM <br /> Owner's Name Address &P r._SONiN 1Cf h1C,Y'V /� _�J. 3 <br /> T--j---- _ Phone <br /> fContractor Address <br /> TYPE OF WELL/PUM NEW WELL ❑ License ES Phone <br /> f WELL REPLACEMENT L3 DESTRUCTION ❑ <br /> f PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR C7 OTHER C3SEWER L{NE5 <br /> j DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WEL THEA WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Q Domestic/Private C1Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> 1-1 Public C1 Other Specifications <br /> fl to Depth of Grout Seal <br /> - i <br /> —Approx. Dept I Eastern ----Surface Seal installed by <br /> Repair Work Done • (] Type of-Pu H.P. <br /> Well Destruction ❑' Well Diameter State Work Done_ <br /> Sealing Material (top 50'1 '1 <br /> Depth Filler Material (Below 50') I <br /> TYPE OF SEPTIC WORK; NEW INSTALLATId REPAIRlADM TION l 1 DESTRUCTION I I ;No septic system permitted if public sewer is O <br /> Installation will serve: Residence CommercialOther available within 200 feet:) <br /> Number of living units_; _L Number of b drooms_ <br /> Character of soil to a depth-of 3 feet: f <br /> 5£PTIC TANK ater table depth <br /> ❑ Type/Mfg Capacit <br /> PING- TREATMENT PLT. ❑ rtments �C <br /> i�I'' - Metho f Dispos <br /> Distance to nearest: Well 1lCC� _7 Foundation iT roperty Line FT, <br /> LEACHING LINE 5 , No. & Length of lines <br /> FiLTER BED - Total length/size <br /> ❑ Distance to nearest: Well I'T Foundation { <br /> Property Line ys <br /> SEEPAGE PITS DepthC-5 Er Si3u <br /> -Size�! Number_ <br /> SUMPS ❑ Distance to nearest: Well *3 f=1' <br /> DISPOSAL PONDS L7 Foundation _FT Property Line �J FT— <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-contractin signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws of California." p y persons subject to workman's c compensa- <br /> tion <br /> applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: /,,3- <br /> F MEN_T USE ONLY <br /> Application Accepted by <br /> Date 6 Area <br /> /P t or Grout Inspection by r <br /> Final Inspection by Date <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 i <br /> FEE j <br /> INFO AMOUNT bUE AMOUNT Rt MITTED CE <br /> RECEIVED BY <br /> DATE PERMIT"NO. <br /> + EH M241REV.)1x51 �}/-� �� �� • <br /> EH 14.26 !1J <br />