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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> it <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> -- Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM' DATE ISSUED <br /> {Complete in Triplicate} <br /> - :. ... :. ..t: _::'tl '�, "'-.7;., - 4. - is : "! `.`:.��e a. . ,• ��. h .: r : :E�, <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 II <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. 'VV rf; <br /> ��'90 Lt/t/�TE' ':St /�' r w ST�4,y: <br /> Job Address City Lot Size PM <br /> Owner's Name /-��3. .�1/ Ai+ 'S��s'�It.r�Address U/A >rL�.L.�d' .>r f Phone <br /> Contractor Address d 'r"Cicense No,G, kN!S Phone C <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION_0 SYSTEM REPAIR,EA, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> `FOUNDATION AGRICULTURE WELL­!_':!" OTHER WELL -" 15IT3/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bolcom ❑ Manteca —'.,Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _-4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. � � TM State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 ) r <br /> TYPE+OF.SEPTIC WORK:t.NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence==_ Commercial_ Other t <br /> Number of living units: 1 Nurriber'of bedrooms <br /> Character of soil to a depth of 3 feet: f E Water table depth <br /> SEPTIC TANK Type/Mfg , V f Capacity No. Compartments <br /> PKG. TREATMENT PCT. ❑' ' ' MethoB.of Disposal <br /> „aa 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 1 Property Line <br /> SEEPAGE PITS ❑ Depth _ Size Number <br /> SUMPS //. I] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL P014 ❑ <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 f <br /> rules and regulations of the San Joaquin Local Health District. <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 s <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 must call for all required iinspections. Complete drawing on reverse side. <br /> Signed X ��i Title: Dater S <br /> } FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> _ Date �+Io Area Q� <br /> Pit or Grout Inspection b�f� Date Final Inspection by JCI ...— Date <br /> Additional Comments: <br /> ❑ Stk 46C-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ 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 /> 4 _ <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 14-281REV.1/657f C <br />