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APPLICATION FOR PERMIT <br />SAN JOAQUIN:LOCAL"HEALTH DISTRICT <br />1601 E. HAZEL ION.AVE. STOCKTON, CA <br />Telephone (209).-466-6781 _ <br />PERMIT EXPIRES.1 YEAR,FROM DATE ISSUED,:. <br />ot��.., - (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 Rt&s'and Regulations of'the San Joaquin <br />Local Health District. �r t <br />1-k A.birccc -N r .,: �U�G /✓Yi ... e.�e <br />�.cnu <br />Y/i �15 , <br />Owner's Name Address <br />Phone <br />7�«l/�(r L� c �%/�: �." <br />Contractor <br />�ln✓ S�/i SHG" "7 / 7 3Z <br />y- <br />Address <br />License No. Phone <br />TYPE OF WELL/PUMP: NEW WELL <br />WELL REPLACEMENT ❑ DESTRUCTION / <br />PUMP INSTALLATION ❑ <br />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 SPECIFICAJIPNS <br />❑ Industrial ❑ pen Bottom ❑ Manteca <br />Dia. of Well ExcavatDia. of Well Casing <br />ig� <br />❑ Domestic/ Private Gravel_Pack _ . _ - _ . ❑. Tracy - _ <br />T� G <br />Type of Casing Specfications-- <br />/qlpe_i <br />❑ Public O Other ❑ Delta <br />Depth of Grout Seal _Type of Grout <br />O Irrigation �=--Approx. Depth E3 Eastern <br />Surface Seat Installed by <br />Repair Work Done _ ❑ Type of Pump: H.P. <br />State Work Done <br />Well Destruction ❑ Well Diameter Sealing Material (top 501 <br />Depth Filler Material (Below 501 <br />TYPE OF.SEPTIC WORK:- NEW INSTALLATION O -REPAIR/ADDITION O DESTRUCTION O .(No septic system permitted if public sewer isL . <br />available within 200 feet.) <br />-_Installation will serve: Residence _ Commercial _ Other - - <br />- Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: - _- <br />_ - - Water Mable depth. <br />SEPTIC TANK O Type/Mfg <br />Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ <br />Method of Disposal <br />Distance to nearest: Well <br />Foundation Property Line <br />LEACHING LINE ❑ No. & Length of lines <br />Total length/size <br />FILTER BED 0___D_ istance to nearest: Well <br />Foundation Property Line <br />SEEPAGE PITS O Depth Size <br />Number <br />SUMPS ❑ Distance to nearest: Well <br />Foundation Property Line <br />DISPOSAL PONDS D _- <br />I hereby certify that I have prepared this application and that the work will be done id accordance with San Joaquin county ordinances, state laws, and <br />- rules and regulations of the San Joaquin Local Health District.- , t <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: "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 applicart�st cc*for mired inspections. Complete drawing oi1reverse side. / % �- <br />Signed���'�- Title <br />Date: <br />F C9D 'yrvlT USE ONLY �r <br />Application Accepted Date Area <br />Pit or Grout Inspection by Date Final Inspecti n by <br />Additional Comments:/5T <br />❑ Stk 466-67810 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 95201 <br />+ EH 13.24 (REV. <br />EH 14-26 : �;t <br />��� <br />FEE 'g,i <br />INFO AMOUNT DUE AMOUNT REMITTED <br />CASH RECEIVED BY <br />DATE <br />�P-E�RMIT'NO. <br />