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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR_FR_OM 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 Sari 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 6- 7 J Lot Size PM <br /> Owner's Name �'"O.._. } Address - Phone _- <br /> Contractor /" t Address License No. A _Phone <br /> TYPE OF-WELLIPUMP: NEW WELL LL WELL_ REPLACEMENT C DESTRUCTION C <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER C <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 4PROBLFM AREA. CONSTRUCTION SPECIFICATIONS <br /> t <br /> +0 industrial, C Open Bottom .E:Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private U Gravel Pack j +0 Tracy' Type of Casing__ Specifications + <br /> {� Public ) Cl Other t Cl.Delta Depth of Grout Seal Type of Grout <br /> l <br /> , l Irrigation 1 Approx. Q pth�`l I Eastern Surface Seal Installed by <br /> Repair Work Done .n Type of Pump .: H.P. _ State Work Done <br /> _4 Nell Destruction G Well Diameter 1 f Sealing Material (top 5o') of <br /> Depth t - Filler Material (Below 50') <br /> I <br /> 1- TYPE OF SEPTIC,WORK: .NFW-INSTALLATION i'I REPAIR/ADDlTION DESTRUCTION I I fNo septic system permitted if public sewer is <br /> 1., s. available within 200 feet.) <br /> Installation will servo: Residence Commercial_ Other <br /> t. Number of living units: Numberiof �sooms _ ek,,, i <br /> y�Character of soll to a depth of 3 feet: ; <br /> _Q` __ )Nater table depth'' <br /> SEPTIC'TANK y-" . ❑ Type/Mfg _ Capacity- ___-- No. Compartments <br /> PKG. TREATMENT PLT. U � ,,;.Method of Disposal <br /> Distance to nearest: Well .... Foundation Property Line <br /> LEACHING LINE No. & Length of tines "� TqTaJ length/size ._—__ <br /> FILTER BED ,(fi D' tancp to nearest': Well _` Foundation�� Property Line <br /> SEEPAGE PITS I I neptn Size r T f Number h <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I I <br /> `- hereby certify that I have prepared this application end-that ahe work will be done in accordancwith-Sarnoaquin county ordinances;.state laws, and <br /> +rules and regulations of the San Joaquin'Local-Health District. ____ z. 1 <br /> i Home owner or licensed agents signature certifies the following: I certify that in the performance of the work for which this permit is issued, f 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 signattira <br /> ;'certifies the following: "I certify that in the performance of the work for which this permit is issued.1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appfi mus cali.fo all red ins tions.y mplele-drawing-on reverse side. t <br /> Signed c! Titre: .L`r�,[ Qate:� <br /> _ FOR DEPARTMENT IJSE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by, �__ �___� Date_____ Final-Inspection.by'' Date <br /> Additional Comments: <br /> Ll Stk 466;6781 t 13.1odi 369-3621 C Manteca-X.823-7104 ,L7_Tracy ..835-6385 _ .__ ' <br /> Applicant- Return all copies to: Environmental Hearth_Permit/Services 1601,E,-H&zefton Ave.;-P.0:i ox 2009,_Stk -CA 95201 <br /> Y <br /> INFO' <br /> AMOUNT DUE } AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. � <br /> + EH13.21(REV.t: _`^"( jo `1-4ti� <br />