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APPLICATION FOR PERMIT <br /> r- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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/o t herein des r This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pu a Rules and Regulations of the San Joaquin <br /> ` Local Health District. <br /> fE ARS �+ <br /> Job Address Z 0 4 ?/vL6&51riVUT t7r,, City&MOfoff/49 ysize PM <br /> V1R�MEJq S R�10ES <br /> Owner's Name _ �/_ ���T� --- Address e�iq/���S ��0� pE, M I one <br /> ContractorGaoy—eI/A/4 AWIZ Address A &x Gf1Cr��r�oR,a License No..V 9 Phone ZL6_ <br /> ' TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK u SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ,AGRICULTURE WELL— <br /> INTENDED <br /> ELLINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑"Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of-Casirig Specifications r <br /> (` Public ❑ Other i1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.-Approx. Dept l I Eastern aSurface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ' s H.P. 1 �''' _ State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material lt,6.50') <br /> Depth Filler Material !Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ):,,DESTRUCTION l 1 (No septic system permitted H public sewer is <br /> { available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> I Number of living units: Number of bedrooms t i <br /> Character of soil to a depth of 3 feet: 3 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � _� � wM-5hod_.of_ Disposal. <br /> r Distance to;nea4est: , _Weld Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation r Property:cihe <br /> SEEPAGE PITS I I Depth Size = f­' Number f Y <br /> SUMPS 0 Distance to nearest: WellFoundation — Property Line <br /> DISPOSAL PONDS . ❑ <br /> r - <br /> I hereby certify that I have prepared this application and that the work will be done'in accordance iivith Saii'ioaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. t y' , <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance t!_``the work for which this permit is issued, I shall not <br /> a employ any person in such manner as to become subject to workman's compensation laws of California." Contractors(tiring or sub-contracting signature <br /> certifies the followin :' rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif } <br /> The applicant I for 1 required inspections. Complete drawing*,d. <br /> ev ide. <br /> Signed X Title: '�O <br /> Date: <br /> 3 , <br /> FOR DEP RTMENT USE ONLY <br /> Application Accepted by _ Date �� Area O/ <br /> Pit or Grout Inspection by Date ..Final Inspection by Date f <br /> Additional Comments: _ <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return at[copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13-24{qEV.i/nsl <br /> EH 14-26 - ��� <br />