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APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1 <br /> Job Address 'r' pK/"q �1 City ►� Lot Size X PM <br /> Owner's Name Xf �Li7N-- Address ` s Phone / z a <br /> Contractof A ess 71 License No.239A;_W Phone �S <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ ELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ } OTHER � <br /> i <br /> 'DlS7ANCE Tb NEAREST: SEPTIC'TAP4K'"-' —— '" SEWER LINES'7 `" 'X ``_DIS - -"PROP.-LINE'-'—'6�"" <br /> FOUNDATION AGRICULTURE;WEL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM ARONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom R ❑ M a Dia. ofWel! Excavation r Dia. of Well Casing <br /> ❑ Domestic/Private 1-1GravelPack Tracy Type of Casing } Specifications <br /> FI Public F1 Other ❑ Delta Depth of Grout Seal l Type of Grout <br /> f <br /> I I Irrigation Approx. Depth I 1 Eastern x Surface Seal Installed by <br /> Repair Wor Type of Pump H.P. € State Work Done_ t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')", RZ <br /> f 1 <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br />` ailable within 200 feet.) <br /> Installation will serve: Residence c f he <br /> Number of living units: Nu <br /> Character of soil to a depth of 3 feet. MRED ' Water table depth <br /> SEPTIC TANK Type/Mfg! �R�fty have � i No. Compartments <br /> 1►�1 �tt <br /> PKG. TREATMENT PIT. ❑ rrp�ti^^ b� I� t� '' MethodofDisposal t <br /> Distance t+o'IretSY�Oein�lelfO-mpleteggjpipeelezd Property Line ' <br /> bv Division. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED El Distance to nearest: Well Foundation y Property Line t <br /> SEEPAGE PITS Depth Size I , � Number f <br /> SUMPSr <br /> ❑ Distance to nearest: Wel! Foundation Property Line'. j <br /> DISPOSAL PONDS ❑ <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 Joaquiri Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perfoemance 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 applicant m for requir spections. Complete drawing on reverse side. r <br /> " Signed s Title: Date: <br /> �I 1 FOR DEPARTMENT USE ONLY r <br /> Application Accepted by ' r .Date ��� 1 <br /> F Area <br /> Pit or Grout Inspection I&�'f 2 • G� 41f_ pa �� nal�I ect n b � `� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 I <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO CK H DATE PERM IV NO. <br /> EH 13-24/REV. <br /> EH 14-28 <br />