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APPLICATION FOR PERMIT <br /> SAN JOAQUIN 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 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. f �` <br /> Job Address �� City/ r Lot Size PM <br /> Owner's Name r� ( �° Address ! ! o e 7 Win Phone-3.3q � C <br /> 17 <br /> Contractor l "l Address! 'D'a 60 t 71 License No-txq(_3a-2� Phone o •c el';7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK c9-00 t SEWER LINES DISPOSAL FLD. PROP. LINE la' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/<?I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> ❑ Industrial CXOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_-_-Vre / Specifications <br /> I`l Public ❑ Other ❑ Delta Depth of Grout Seal ZZ110 Type of Grout/',-,Zxe�� <br /> Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by O.-T e t/ R r <br /> Repair Work Done ❑ Type of Pump r> H.P.-Z-- State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I (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 of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ -1 Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line <br /> Y <br /> LEACHING LINE ❑ No. & Length of lines e Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ) Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <br /> 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 Dt%trict- <br /> 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 this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic�antt must call for all required inspections. Complete drawing on reverse side. <br /> Signed X. L Gl m Olti A' !&A 19,�A Title: /t - _ Date: U p <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - y Date O Area <br /> Pit or ro t Inspection by'� r' Date Final Inspection by `' Data <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 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH13-244REY-1/851 <br /> EH 14-26 <br />