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� APPLICATION FOR PERMIT � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON 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. 18M for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. / <br /> Job Address 7� A.41 % city ,//�� G, Lot Size PM)�4 <br /> Owner's Name / /e � --Address �og`V o'•e A,, 9 �/�-.� �Ph60M <br /> Contractor G Address�C/. Icense No. gzr CAI/ Phor a <br /> TYPE OF WELL PUMP: NEW WELL RT WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION ❑ 1SVSTEM REPAIR El -- OTHER ❑ I'A0ki�W1 . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE ,WcJ'/UI <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /r <br /> ❑ Industrial ❑ O n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ElDomestic/Private Gravel Pack O Tracy Type of Casing Specifications <br /> ❑ Public �p�❑;P91gr ❑ Delta Depth of Grout Seal SS •'� Type of Grout <br /> ❑ Irrigation - //� pprox. 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 sewer is <br /> available within 200 feet.) <br /> Installation wResidence— Commercial_ Other / <br /> Number of living units: bar of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well. Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sill- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth be 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 Dislript. . , <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."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 <br /> —must call for all required inspections. Complete drawing on reverse side. <br /> Signed X 172;; ea I Title: Za jgr Date: 3-.0Y­x%`7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Date Area <br /> Pit or Grout Inspection by r' \L Date r Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO '//y /[ �/ <br /> i EH 13-24(RM 1/Bs) /�� /� / /J IV -.io / / <br /> EH 1426 f <br />