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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LA 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 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..1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �7t�C� ' L(/`% �� CityLLot Size PM <br /> Owner's Name //®� �. i �— Address __!(.�'�`, ., G.lc���� Phone 9d ` <br /> Contractor R Address License No. Phone <br /> .yam r I }Ilr r <br /> TYPE OF WELL/PU . 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications <br /> ("1 Public Ll Other ❑ Delta .Depth of Grout Seal Type of Grout _. <br /> 1 1 Irrigation _ Approxi Depth I I Eastern Surface Seal Installed by <br /> w� fir. <br /> Repair Work Done ❑ Type off Pump H.P. State Work Done O <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEWLINSTALLATION I I REPAIR/ADDITION LI DESTRUCTION (No 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 offeet: Water table depth <br /> SEPTIC TANK ,❑ _ Type/Mfg Capacity No Compartments <br /> PKG. TREATMENT PL Te❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ NO & Length of lines Total length/size <br /> FILTER BED ❑ Distance to:nearest: Well Foundation Property Line <br />' <br /> I <br /> p SEEPAGE PITS I I Depth` Size Number <br /> f SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS. 1,E] ._ <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 /> p 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"h s permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br />' The applic t call for all require i spectio s. C mplete drawing on reverse side, <br /> I <br /> l Signed�.��. �1L�` Titley Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedby Date Area \J <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: 'C <br /> ❑ Stk 466-6781 - ❑ Lodi 362 ❑ Manteca 823-7104 f TPWacy 835- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> t� w <br /> 4 +.EH 13-24IREV.ties) �- <br /> P EH 11.28 h�?9ll_e+✓�/ !O� <br /> g 20-0-T`- M-1\1 !t04__VTOL-2' ' 11\4:�6 <br />