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APPLICATION FOR PERMIT <br /> Y•: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1601'E-HAZEL-1 ON AVE., STOCKTON, CA <br /> Telephone pone {209} 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> =, , <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. 186'1 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address IS <br /> Alf- <br /> City O�l — Lot Size PM <br /> Owner's Name Address <br /> /s,, Phone i <br /> Contractor s la° �o�ow Address r o <br /> I License No, <br /> TYPE OF WELL/PUMP: —"-019-0-2- phone ! { <br /> NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATIO ❑ DESTRUCTION ❑ { <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER It, <br /> SEWER LINES DISPOSAL FLD.—A* PROP_ LINE �y <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom [-] Manteca <br /> Dia. Of Well Excavation G f <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia, of Well Casing <br /> Type of Casing—A�z r <br /> ❑ Public yAft� p Other ❑ Delta Specifications <br /> Depth of Grout Seal 1 <br /> ❑ Irrigation hrtoe� _--Approx. Depth ❑ Eastern Type of Grout <br /> Repair Work Done ❑ Type of Pumpurface Seal installed by <br /> H.P.HPr <br /> Well Destruction 9 Well Diameter .41 r State Work Done <br /> / Sealing Material (top 50') <br /> Depth I- of Filler Material {Below 50') y ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,'REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is <br /> Commercial Other <br /> Ins ion will serve: Residence available within 200 feet.) <br /> � <br /> Number of i units: Number of bedrooms ~—~ <br /> Character of soil to th of 3 feet: <br /> SEPTIC TANK ❑ Ty f er table depth <br /> Capacity <br /> PKG. TREATMENT PLT. [D No. Compartments <br /> Method Of Disposal <br /> Distance to nearest: 1 ndation <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of line <br /> FILTER BEDTotal length/size <br /> ❑ Distance t rest: Well Foundation <br /> Property Line i. <br /> i <br /> SEEPAGE PITS Depth Size <br /> SUMPS ❑ Distance Number <br /> to nearest; Well Foundation <br /> D AL PONDS ❑ Property Line <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, <br /> 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, 1 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-contracting signature <br /> certifies the following; "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required in ctions. Complete drawing an reverse side. <br /> Signed XTitle: <br /> /p� Date: <br /> F �DPAM �SElONLY GEG 6�i7�k f C�GfxiT FOR �af� G1Fl�/++t, <br /> Application Accepted by e. Date :Z <br /> Area <br /> Pit or Grout Inspe o y Date_ - <br /> . Final Inspection by� ����. •,�� pate�_ 3 <br /> Additional Comments: } <br /> Cl 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO O RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV,1/651 <br /> EH 1428 S A `i}♦� ��� " 7 27L <br />