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APPLICATION FOR PERMIT <br /> Y I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> NV t <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA- <br /> Telephone <br /> g <br /> Telephone (209) 466-6781 No - , <br /> PERMIT EXPIRES 1 YEAR FROM DATEISSUED <br /> I . . (Complete in Triplicate) T � <br /> l 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 /> i Local Health District. ` " m <br /> Job Address City Lot Size 61 ISS ' <br /> .. <br /> Phone PM <br /> Owner's Name ddress - <br /> Q <br /> Contractor.` Address—ALI License No. Phone /�v✓ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> i <br /> INTENDED USE TYPE OF WECL� PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( ,, <br /> ❑ Industrial ❑ Open�Bottom .❑ Manteca j Dia. of Well Excavation Dia. of Well Casing `V <br /> ❑ Domestic/Private <br /> LI Gravel Pack <br /> ❑ Tracy Type of Casing Specifications \ <br /> ❑ Public ❑ Other f "Delta Depth of Grout Seal . Type of Grout <br /> 4� <br /> ❑ Irrigation rox. D <br /> 9 — APA epth_. ❑ Eastern FSurface,Seal Installed by <br /> Repair Work Done ❑ T 5-r y ' <br /> p Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameterr Sealing Material (top 50') <br /> Depth I Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> 3 available within 200 feet.) <br /> Installation will serve: Residence 'Commercial_ Other'---=A J-%'_.: J <br /> Number of living units:4__ Number of bedrooms ._ _ \\ ' <br /> Character of soil to a depth of 3 feet:f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.'Compartments <br /> PKG. TREATMENT PLT. Ll i Method of Disposal <br /> Distance to nearest: - Well Foundation TProperty_Line _ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> f <br /> ,. FILTER BED EJDistance to nearest: Well Foundation Property Line `h <br /> i SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> 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 /> I 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." 1 <br /> I The applicant must calf for all require ections. C <br />� q � pl drawing on reverse side. <br /> l Signed X_ �, � Title: Date: <br /> R ARTMENT USE ONLY <br /> Application Accepted by /__Q�CC.,,� '1�1L.– Date 3 n 9 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: Jr <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 EI 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 AMOUNT DUE ' AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> + EH 61013-24(REV,1i85) FJ <br /> EH 14-28 i-'4 , <br /> �i <br />