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F <br /> II } <br /> - .- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL',HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 I ) <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'Joaqu-in 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.* �' Y.i�*` t ' <br /> City-,577r;().J - Lot Size PM <br /> Job Address � � � <br /> Ake <br /> Owner's Name 56 Ht r255&IUB - Address Phone <br /> AA ,X�• ,ed <br /> Contractor/r'/��� 5 Address ? License No. �a�f Phone <br /> TYPE OF WELL/PUMP:' NEW WELL ❑ WELL�RREPLACEMENT ❑ DESTRUCTION ❑ <br /> ! PUMP INSTALLATION Wr 9V°4-14JE�/=AQYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. _PROP. LINE <br /> -. <br /> -- "- FOUNDAT101V . AGRICULTURE WELL OTHER WELL P11 S/SUMPS <br /> INTENDED USE j TYPE QF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LJ-Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing s <br /> [1 Domestic/Private El GravehliPack C1 Tracy Type of Casing Specifications <br /> / {� <br /> F All 5 <br /> ❑ Public C B70ther ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation -?-'L-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ IIT a of.k ump � H•P• State Work Done �F <br /> Well Destruction i❑ Well Diameter Sealing Material (top 50') <br /> _ fa4 .I � <br /> LDepth �� 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 <br /> Number of living units: IM Number of bedrooms <br /> Character of soil to a depfWof 3 feet: Water table depth <br /> SEPTIC TANK ❑OI,Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑i: <br /> j Method of Disposal a <br /> } Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑'l DistaInce to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth) Size t Number - <br /> ij <br /> SUMPS- ❑ Distance to nearest: Well W Foundation Property Line <br /> DISPOSAL P_ONDS...CI 1-_- . <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 /> rules and regulations of the[San Joaquin LocallHealth 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 mannar'A to becom'subpi �t,tq-workman's,cor�pe�sation laws of�Calffornia."Contractor s hiring or sub-contracting signature <br /> certifies the following: "I cert ify that in the perfo maihce.,af the worliiorVAC"h iFns permit is.rssued,I shall employ persons subject to workman's compensa- <br /> t tion laws of California." <br /> The_applicapt . _t.. II _or _Il-req pect�ions•.Complete drawing pn.rever. ide, _. ;__ ;.. -.-�- • <br /> Signed Title: r <br /> Date Z <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by :I Date ° 'I ti tArea <br /> r <br /> Pit a5-Grout Inspection by I� ) Date Final Inspection r j.' 3 Date G <br /> Additional Comments: All <br /> t ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6385 <br /> r <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 CASH <br /> RECEIVED BY DATE LPERMIT'NO. <br /> INFO 6+ EH 13-24(REV.t i e 5) p <br /> EH 14-28 <br />