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APPLICATION FOR PERMIT f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { l� <br /> N� 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> a Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR PROM 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. s <br /> Lot Size PM <br /> Job Address' 096� <br /> 7_1 <br /> Phnna <br /> Motel ❑ Other ---- ------------------------- <br /> ` "—Corina in' c. IViirrlr�y�fJ,prlrnnme Grinder W1-_ .Lot Size - _ 4Q <br /> TYPE OF'WELL/PUMP: NEW WELL EJWELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION Q SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: 5EPTlC TANK' '=SEWER LINES DISPOSAL PROP. LINE <br /> ."`� - "�"` '� <br /> FOUNDATION AGRICULTURE WELL _WELL PITS/SUMPS <br /> _ INTENDER USE TYPE OF WELL PROBLEM AREA, C UCTION SPECIFICATIONS ' <br /> Dia. of Well Casing <br /> 171Industrial L) Open Bottom C3Manteca Dia. of Well Excavation— <br /> [I Domestic i Private <br /> xcavation[IDomesticlPrivate Cl Gravel Pack acy Type of Casing Specifications , <br /> M Public f41 Other ❑ Delta Depth of Grout Seal Type of'Grout <br /> I"I Irrigation pprox. Depth I Eastern Surface Seal Installed by - <br /> RepairFWork Do Type of Pump H.P. J' �~ y State Work Done_ <br /> Well De tion ❑ Well Diameter Sealing Material (top, <br /> r <br /> m" Depth Filler Mate6al (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION, m(No septic systepermitted if public sewer is <br /> available within,2M 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: _ __ Nater table depth; <br /> SEPTIC TANK El Type/Mfg.a _ Capacity No. Compartments <br /> ,`1 - 1Vlethod oUDisposbi ,. <br /> PKG. TREATMENT PLT. ❑ v e <br /> Distance to nearest: Well Foundation Prriperty Line ' <br /> 4 w e' g' <br /> LEACHING LINE ❑ No. & Length of lines a 'Total length/size c. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property kine <br /> SEEPAGE PITS I-I Depth Size Number <br /> SUMPS El Distance to nearest: Well4_.--- Foundation Property Line j <br /> DISPOSAL PONDS ❑ rtr ' <br /> I hereby certify that I have prepared this application and that the work will'be dl�in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. s. <br /> Home owner or licensed agent's signature certifies the following:,:Fi++~�rtify that injhe performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to worktri8hs 6ompen-4tion laws,of California."Contractor's hiring or sub-contraciing signature i <br /> certifies the following: y <br /> I certify that in the performance of the workyUr�hich 1k `permit is'issued, I shall employ persons subject to workman's compensa- i <br /> tion laws of California." 7fl <br /> The applic t must call for all required inspections. Complete.drawI .":on'lp e srde <br /> ati <br /> Signe - �fitle � . <br /> FORy EPARl MEN7;VSE`ON LY - >w�l= . <br /> =f Application Accepted by Date QTea_ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> ,DaterI _. <br />� „apt.. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 a 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 AMOUNT DUE AMOUNT REMITTED C SH K 0 RECEIVED BY DATE PERMIT'NO., i <br /> INFO <br /> + EH 13-24(REV.t/s 51 j5 A1717,76 <br /> EH 14-26 <br />