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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) 466-6781 O <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) O <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install a wolrk herein described. This applicatio, is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t les and Regulations of the San Jo;,cluin <br /> Local Health District. <br /> Job Addresses►1 ci��$�� r <br /> 1 - Lot Size PM _ <br /> Owner's Name C r 1_ .. Of .S (`�: � C <br /> Address ''�/ �...%/ �/K/`cr. % �C'i - <br /> Contractor Vf- Address..�5�_i ►lie_ �'� ��r:/as/�' Phone <br /> - <br /> TYPE OF WELL/PUMP: License No. �'/lt �l?Phone a/;, <br /> NEW WELL WELL REPLACEMENT O <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> N <br /> DISTANCE TO NEAREST: SEPTIC TANK ON SYSTEM REPAIR El OTHER � f,10 <br /> SEWER LINES /,"/-j DISPOSAL FLO. l`%i <br /> FOUNDATION /L'/� PROP. LINE ��� <br /> AGRICULTURE WELL AW OTHER WELL /6' <br /> INTENDED USE —/� PITS/SUMPS �1 i� <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom F-1 Manteca <br /> Dia. of Well Excavation <br /> D Domestic/Private Gravel Pack El Tracy �� Dia. of Well Casing <br /> I"1 Public y Type of Casing_ �, <br /> Fl Other Delta Specifications <br /> I I Irrigation Depth of Grout Seal /G> <br /> _ Approx. Depth I I Eastern Type of Grout <br /> Repair Work Done D Type of Pump Surface Seal Installed by te u Work <br /> Do c&— <br /> Repair <br /> State Work Done <br /> Well Destruction D Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK D Type/Mfg Water table depth <br /> PKG. TREATMENT PLT.El No.No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE D No. & Length of lines <br /> FILTER BED D Distance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS I I Depth <br /> SUMPS Size _ Number <br /> l_l Distance to nearest: Well 1 <br /> DISPOSAL PONDS El Foundation Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ancf <br /> rules and regulations of the San Joaquin Local Health Di?:trict. <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 /> certifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." <br /> p y persons subject to workman's compensa <br /> The applicant st call fo rr IIreed ' spections. Complete drawing on reverse side. <br /> Signed X C�``�-tC� <- <br /> Application <br /> t..: <br /> F R DEP ENT USE ONLY Date: <br /> Application Accepted by <br /> 7 <br /> �r� Are <br /> Pit or Grout Inspection by `7 Date <br /> Final Inspection b may <br /> Date ? <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 <br /> Tracy 5-6385 <br /> Applicant- Return,all copies to: Environmental Health Permit/Services 1601 E.0 Hazelton 3Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> EM 13-24(REV.I sr <br /> INFO AMOUNT REMITTED RECEIVED 8Y <br /> DATE PERMIT NO. <br /> i x <br /> EH 14.26 a� <br />