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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 , „ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �r <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 tfie Rules and Regulations of the San Joaquin <br /> Local Health District..„rr;er� <br /> Job Address 6_3 oy 3' ' 't clu e_ +e ice. city Z:yo—oC Lot Size %�X/z 3'� PM J <br /> Owner's Name �c��i .w e � ,t`K—f--41ifC Address �� J .0 e4—l..s5-� <br /> _ '�` ."C Phone S` <br /> Contractor I Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACfMEN1T ❑" _DESTRUCTION ❑ <br /> _ __ <br /> PUMP INSTALLATION ❑ �^ SYSTEM REPAIR El „ 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 SPECIFICATIONS ` <br /> fI ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �J <br /> ❑ Domestic/Private ❑ GravelPackED Tracy Type of Casing Specifications <br /> ❑ Public LJ Other( D Delta Depth of Grout Seal Type of Grout <br /> 4 � <br /> ❑ Irrigation ___gpproxt Depth Lll Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump_, I H.P. L State Work Done <br /> Well Destruction ❑ Well Diameter i Sealing Material{top'50'1 '` I' <br /> Depth Filler Materiol-IBeloW 50:1,'` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> LLATION REPAIR/ADDITION ❑ DESTRUCTI <br /> Q � I �(Noseptic system permitted if public sewer is <br /> able within 200 feet.) <br /> Installation will serve: Residence I Commercial_ Other_.._,_�„ i <br /> Number of living units: Number of bedroIoms i <br /> Character of soil to a depth of 3 feet— <br /> - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ 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 /> SEEPAGE PITS ❑ Depth Size I Number <br /> SUMPS ❑ Distance to nearest: Well l Foundation Property Line <br /> DISPOSAL PONDS D �. ? <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: "hcertify that in the performance of 6e 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." 1 I - --The applicant must call for al required inspections. Complete drawing on reverse side. <br /> Signed Title: l <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date — _ Area d3 <br /> 69A-4 <br /> Pit or Grout Inspection by��� �' t. pet _ '� -Final-Inspection by Dai _ � T <br /> Additional Comments: L,lQ <br /> ❑ Stk 466-6781 ❑ Lodi 3699-3621 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 95201FEE j <br /> INFO AMOUNT DUE AMdUNT REMITTED C K RECEIVED BY DATE PERMIT''No. <br /> + EH 41REV.1/B 5] <br /> EH 14-2 4 �^. �� <br /> J `W' 3 ��8 <br /> f i <br />