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r- - <br /> f <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �C. 1601 E. HAZELT ON 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. <br /> Job Address :Z ` of Cit dd ( Lot Size PM <br /> Owner's Name �� Address Phone <br /> Contractor Via /f ��' Address I (.� +F--+ 4" `I License No '73 U 3Phone,_3 9k Z R �C <br /> TYPE OF WELL/PUMP: NEW WELL CK� WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 PUMP INSTALLATION 0� SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK m 7S SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSAC�o f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS <br /> ❑ Industrial ,Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing <br /> ADomestic/Private 17Gravel Pack ❑ Tracy Type of Casing O_�� Specifications �p <br /> F-1 Public ❑ Other (_1 Delta Depth of Grout Seal Type of Gr ut e"nii__�� <br /> i I Irrigation I Z_Approx. De.p�th jjI__I Eastern }} J urface Seaf Installed by se <' yt <br /> Repair Work Done ❑ Type of Pump _-3y h H.P. State Work Done — <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material I Below 501 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ` f Installation will serve: Residence_ Commercial_ Other <br /> ry Number of living units: Number of bedrooms <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> -' <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 I I Depth <br /> + SUMPS ❑ Distance to nearest: 'Well's �^-�" Foundation ' Property Line i <br /> DISPOSAL PONDS ❑ <br /> hereby.-certify that I ha_ve.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 Di%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-contraciing 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." <br /> The applicant m t call for alll ree !red inspections. Complete drawing on reverse side. <br /> Signed� / NA8A A.2Q Qkt.� Title: _S �G /�1'– � _ _ Date: <br /> FOR-DEPARTMENT USE ONLY <br /> Application Accepted'by Date r, 46 I Area <br /> Pit or ro Inspection by ate �>Z Final"Inspection by atjDate-T � <br /> J <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 95.201 <br /> --...,tom �.�.�--- --.. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. 1 <br /> INFO CASH <br /> + EH13-24IREV.1/A 51 057 <br /> EH 1426 ULX4 <br />