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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 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 i <br /> Local Health District. <br /> r <br /> Job Address 2 G� City ]— t Size._l //t .00 <br /> \�1 <br /> t Owner's Name J , Address 2 !1_U ^� Phone ✓ _ <br /> s �(� E oS y�r � -S ?Z7 . r, . <br /> ' Contractors Adress l 2 license No. Pho9ne r <br /> TYPE OF WELL/PUMP: INEW WELL­ <br /> 0 A WELL REPLACEMENT ❑ DESTRUCTION ❑ f - <br /> PUMPINS7ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER L ESDISPOSAL FLD. PRdP. LINE y <br /> ' 1 FOUNDATION AGRICULT RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ON UCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom 171 Manteca . of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ TracyID <br /> e of Casing Specifications ' <br /> ❑ Public ❑ Other ❑ Deltathof Grout Seal Type of GroutI I irrigation —Approx. Depth I I Easternace Seal Installed byRepair Work Done ❑ Type of Pump .P. - State Work Dane -1 <br /> I Well Destruction O Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material(Below 501 <br /> e <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> ' ✓ available within 200 feet.) <br /> Installation will serve: : Residence_ Commercial_ Other <br /> Number of living units:_ Number of bedrooms <br /> ' Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/N,ilgi ' CapacitylLffff: No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of•Disposal <br /> � .J <br /> Distance to nearest: Well�T Foundation Property Line V 0,o <br /> ' LEACHING LINE ❑ No. & Length of lines Z - Total length/size <br /> FILTER BED ❑ Dis+tance to It Well ll. ) 0 Foundation_-t._0 Property Line <br /> r. <br /> '. S PITS I I'-Depth' -, 1' ire _ <br /> LIMPS-) �; Distance'to nearest: Well Foundation Property LineaTv <br /> D=Q AL PONDS ❑('-.:., f <br /> i <br /> ' I hereby certify that I have p1repared this 9pplication 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 D3trict. <br /> Home owner or licensed agent'qq`signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> z employ any person in such manher.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 /> f. <br /> The applicant ust calf for requiretl " spections. Complete drawing on reverse,side. <br /> Signed X� � - Title: `OLIC In I Date: 2'— 17- <br /> or <br /> 7 <br /> IFOR DEPARTMENT USE ONLY <br /> Application Accepted by i=_�„/ " ' Date Z? / 7 <br /> f Area p <br /> Pi[or Grout Inspection by �''-'� Date Final Inspection by Date 2 Z o <br /> ' Additional Comments: <br /> ❑ Stk 466$781 'l ❑ Lodi 369-3621 '❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> ' - Applicant - Return atl copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEINFO 'AMOUNT DUE AMOUNT REMITTED /�`_—CA-SH `^RECEIVED By DATE „ PERMITNO. <br /> ' <br /> 1♦'fll13.211REV.r/n5t 0-:.G1-C)�.- f,i®'.L { 1. 1 2 17 #? " 318 <br /> Ea X (/ /� <br />