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APPLICATION'FOR PERMIT �� <br /> SAN JOAO.UIN 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 applicaVo <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 /> "f` 1��� Lot Size PM L� <br /> Job Address i 3� 43� �� ��1RfZ��r.� `' City �. <br /> l► Owner's Name FP, K ll1—(AG,0R Address 0 R Phone 202 g <br /> ContractorAddress License No. Phone.— <br /> TYPE <br /> hone_TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT. ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial rt❑ Open Bottom ❑ Manteca :Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy /Type of Casing Specifications <br /> i <br /> f l Public F Other F1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0 Type of Pump H.P. 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 1.1 REPAIR/ADDITION 11, DESTRUCTIONINo septic system permitted if public sewer is <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: Water table depth S1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> t SEEPAGE PITS F I Depth- Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation ' f Property Line <br /> DISPOSAL PONDS ❑ _ c <br /> I 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: "I certify that in the-performc)nce 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 /> yyy tion laws of California." ¢ <br /> The applican ust call for all requ011 inspections. Complete drawing on reverse side. <br /> Signed Title: ate: �" l 7— <br /> FOR DEPARTMENT USE ONLY pw� <br /> Application Accepted by Date \-- " Q ` 1 Area - F4 <br /> Pit or Grout Inspection by Date Final inspection by\" <br /> Additional Comments: V110 <br /> ❑ Stk 466-6781 ❑ Lodi 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> t <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO CA9t <br /> + EH1 <br /> 3-24(REV.I/AS) <br /> S <br /> EH 1a-26 <br />