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c <br /> APPLICATION FOR PERMIT <br /> k <br /> SAN JOAO,UIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ;'• �.- ry (Complete in Triplicate) : r <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 incompliance 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 � 74 C _57 <br /> - City} r(j -Lot Sias PM <br /> Owner's'N ame _ !O Address ✓ C• Phone v !2-1 <br /> i Contractor T Ul /' A(I&ss l/ !1l T License No. Phone 7 <br /> TYPE OF WELL/PUMP: NEW WEt':rT,:a WELL REPLACEMENT DESTRUCTION ❑ <br /> k <br /> ' PUMP INSTALLATION `% SYSTEM REPAIR C1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL 171-13.729'r- PROP. LINE <br /> _-FOUNDATION- AGRICULTURE WELL, OTHER WELL _ PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL P OBLEM AREA CONSTRUCTION SPECIFICATIONS f/ ltf <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casingf <br /> ' Qomestic/Private ravel Pack ❑ Tracy Type of Casing C, ' Specifications G� f <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sealtrkp Type of Grout <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by 11 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: 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 r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth , <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line <br /> l LEACHING LINE ❑ No. & Length of lines Total length/size <br /> k FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ — <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 <br /> I 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 /> j 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 /> i certifies the following: I certifythat in the performance of the work for which this permit is issued,1 shall employ p p y persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu al or all re ire'l in actions. Complete drawing on rave e. <br /> f <br /> SignedTitle: �. Date: <br /> f r ! FOR DEPART ENT USE ONLY p <br /> Application Accepted by Date 4 <br /> Area �r+� <br /> Pit or Grout Inspecti n b�y� r Date Final Inspection by Al Date <br /> i �I�/ r n r <br /> Additional Comme t f -� <br /> e � <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 1 - ❑ Track 835-6385 O ! � 1 a4u��� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 <br /> E Hazelton Ave., P.O. ox Stk., Cp 952o1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> ' +EH 13-241FiEV.7/e57 - 1 J <br /> - �� <br /> EH 1428 V� �}� <br />