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a� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I'ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> U - (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. 1861 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District: <br /> City C % Lot Size PM <br /> Job Addressv �` ; r <br /> }.., L Q <br /> ` r ress <br /> ? � 9 / Phone <br /> Owner's Name eaX _ Add —J <br /> Contractor ve Address <br /> License No. -01 Phone <br /> TYPE OF WELL/PUMP: NEW WELL IJ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —rte t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ! <br /> ED Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> / <br /> Type of Casing Specifications <br /> El Domestic/Private ❑ Gravel Pack El Tracy Type of Grout <br /> El Public ❑ Other. Y F1 Deltby <br /> a <br /> Depth of Grout Seal <br />" 1-1Irrigation 1-•-- _-=-Approx?Depth-- d Eastern' Surface Seal Installed State Work Done <br /> Repair Work Done El Type of Pump <br /> H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION r DESTRUCTION ❑ alvailablelwitri n.200 stem permitted if public sewer is <br /> Installation will serve: Resj'dence Commercial� OtFiet, <br /> Number of living units: �d— y Numher o be rooms __ t', <br /> t Water table depth <br /> Character of soil to a depth of 3 feet: _ - <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> } Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distnca o-nearest:. Well - Foundation Property Line <br /> ' <br /> LEACHING LINE �No..& Length of lines �}� --t-. �Q t ���To�tal length/size <br /> r l• Foundation ". Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> —/ Number <br /> SEEPAGE PITS j t� De } f Property Lined <br /> SUMPS f ❑ Distance to nearest:'-'�--�WeII�-1 0: Foundation r <br /> DISPOSAL PONDS : ❑ j. f <br /> I hereby certify that I have prepared-this application.,and-thatthe 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, permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following. "I certify that in the performance of the work for which this <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 work's compensa- <br /> tion laws of California." �'�, v..-, 4�.-•,. :-'_ "� ., `, <br /> The applicant must tail for all required inspections. Complete drawing on reverse side. <br /> i f t, Title: / '" Date: <br /> r Signed @. k <br /> 4 <br /> t FOR DEPARTMENT USE ONLY <br /> .' (1 Date Area <br /> Application Accepted'by JD <br /> + tl I• ' Date Final Inspection by Dater <br /> Pit-or;Grout Inspection by � �I <br /> Additional Comments: ` <br /> k 0 Stk 466-6781 ' Lodi 369-36'11 ❑ 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 /> 'CK <br /> FEE AMOUNT DUE AMOUNT REMITTER '° as CASH y� RECEIVED BY DATE PERMIT N0. <br /> 1NF0 <br /> + EH 13-24(REV.1/B5) 6� � V11 <br /> EH 14-25 <br />