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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 <br /> Local Health District. <br /> Job Address / �-� �'z`Y r �`-T' �f �h <br /> // City!' z ot clSa 'L � �� <br /> e � pM <br /> Owner's Name J4- YYI 1 '�VX Address M I+e Z-0 CI-) Phone _V_-/ 6 <br /> Contractor Address License No. Phone <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 WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications UJ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> y ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public Samaria <br /> available within 200 feet.) <br /> — Installation will serve: ce L Commercial_ Other <br /> Number of Irving units:AlNumber of/h.edrooms <br /> Character of soil to a depth of 3 feet: �fYY7 [_d A-rn Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 3 <br /> PKG. TREATMENT PLT. ❑ J Methodof Disp I <br /> Distance to nearest: Well._ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ' n / <br /> FILTER BED W Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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: "1 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 Califomia." Contractors 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 must call for all required inspections Complete drawing on reverse side. <br /> Signed X Tide: 1j,�,i Date: <br /> _ FOR DEPARTMENT USE ONLY .. �..P/ <br /> Application Accepted by Date -� �-�6 ' Area <br /> Ph or Grout Inspection by Date Final Inspection by � Data �a <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 95201FEE <br /> ,1� <br /> NFO AMOUNT DUE AMOUNT REMITTED C.4KSH RECEIVED BY DATE PERMITNO. <br /> '* EH 13-24 <br /> EH <br /> 1Q• 70. 3756 1 rift. 1 g,21/5'9 <br />