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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 �` <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Z U V h^ d r-c <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'f �✓it k J <br /> Y 1 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address _. r�e�� (�3' City ' ,Lot'Size PM <br /> Owner's Name Address 1 Phone <br /> d� <br /> Contf actor Address3+ 7 iJ! _E o`— ' License No. Phone <br /> TYPE OF WELL/-PUMP: NEW WELL © -WELL REPLACEMENT El DESTRUCTION -C7 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> y . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LA <br /> ❑ Industrial ❑ Open Botiom ❑ Manteca Dia. of Well'Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications <br /> M Public Cl Other j ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _..Approxi: Depth I ] Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Desiruction, El Well Diameter Sealing Material (top 50'1 <br /> Depth t Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION I ] DESTRUCTION DeNo septic system'permitted if public sewer is <br /> ailable within 200 feet-) r <br /> Installation will serve:' Residence Commercial_ Other <br /> Number of living units: Number of bedrooms I <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. 0. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line '1' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> FILTER BED ❑. Distanced nearest: Well oundati�onProperty Line <br /> SEEPAGE PITS I I Depth I i Size ''Number _ t <br /> SUMPS LlDistance to nearest: Well Foundation_ ': Property Line <br /> DISPOSAL PONDS ❑ �.. t I <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc,e'with San-Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. (J I <br /> Home owner or licensed agent's signature certifies the foltowing: "I certify that in tha performance of the work for which this permit is issued, i shalt 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,Che work for which this permit"is issued�'shal!efnpioy persons subject'to workman's compensa- <br /> tion laws of California:" , r <br /> The applicant st ca r all required in i s: Complete drawing on reverse side. r 1 <br /> { o -? <br /> Signed X Title: ' r f .Date: r <br /> t FOR DEPARTMENT USE ONLY i <br /> Application Accepted.by Date Area <br /> f _ <br /> Pit or Grout Inspection h 1-'�-..Date— -- ---�--- Final-Inspection by- — Date <br /> Additional Comments: A"� <br /> ❑ Stk 466-6781 17-Lodi•"369=3621"^`"---❑-Manteca`-823• l —"'�" D-Thid—V$35 6385 <br /> Applicant - Return all copies to: Environmental Health Pelrmit7Services 1601 F. Haielton Ave:?P.A. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE '! AMOUNT REMITTED C RECEIVED BY DATE jPERMI7'NO. <br /> ♦ EH 13-241REV.'iiNs) �f�} " <br /> EH 14-26 - !Y�{J1-7 <br />