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awe ` #,` APPLICATION FOR.PERMIT <br /> r, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> „ 1601 E. HAZELT ON AVE., -STOCKTON, CA <br /> : i <br /> ' Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> { ,_ <br /> (Complete in Triplicate) "IS <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work herein.described. TFA application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. y < <br /> Job Address Q � a �� + 'G, � f <br /> Gity S Lot Size <br /> = Owner's Name Y� Gt !� Address o -'��r�C ' yyP S4��-Tpfione1 0A 9f YY 7 a <br /> Con`tracfor License No. _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT Cl DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ �. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t" <br /> i INTENDED USE .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca S-, Oia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ` <br /> Cl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' <br /> ❑ Irrigation ---Approx. D th ❑ Eastery„�� Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum H. State Work Done 011 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 01 <br /> Depth Filler Material (Below 501 C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r _ I available within 2b0 feet.) <br /> I <br /> "Number <br /> Installation will serve: Residence_ Commercial_ Other <br /> of living units: Number of bedrooms <br /> E Character of soil to a depth of 3 feet: Water table depth <br /> �S'EPTiC-TANK—❑"°Type/Mfgr`e.t. ------ Capacity No. Compartments <br /> PjCG.TREATMENT P.LT;_❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEAGHING LINE & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:''•,y Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth �' Size Number j <br /> T.SUMPS.J.-- :. i <br /> } ,❑ t.Distance to Well Foundation Property Line <br /> DISPOSAL PONDS4­t~_ 1i ^d- f <br /> . Irl�hersby 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 /> 11„r6les and regulations of the San'JoagGinrLocal 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 manne`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'perforrFAde of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws ofC`aff6irriia.; <br /> The applican ust call for all required'i ctions "Complete drawing on everse side. <br /> -Signed Title: ��rni Date: "Y} a )�"b <br /> FOR DEPARTMENT USE ONLY t <br /> Application Accepted by Date `z f' Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 RKmanteca 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 /> 4 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED <br /> a INFO_ - ---.CASH RECEIVED DATE , PERMIT"NO..-. ._ - <br /> + + EH 13-24(REV.I B5) <br /> EH 14-26 �O f 3 it� t.,-3 FF-7 <br />