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. i <br /> r° f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> G 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PAYMENT <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in'Triplicate) �yf� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and or install the work h {fie tie 1 application is <br /> I made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weNpump and the Rules a Regulations 401 N �o�th�eALjHaquin <br /> Local Health District. ! „Pa RVICES <br /> �//�/ �,� PFRMI�ISE <br /> "Jobp g S -" TA cit Lot Size PM <br /> Address <br /> } <br /> Phone <br /> ` �yyl uLq ti , n Address <br /> Owner's Name fid, <br /> Address <br /> Contractor Pt5s <br /> License No, 02�—Phone <br /> DESTRUCTION ❑ �I -5-4 uJA+e-r r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i <br /> PUMP INSTALLATION ❑ - - _ - -SYSTEM REPAIR ❑F OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TAN K. ,��'..— <br /> SEWER LINES ' DISPOSAL FLD.L��- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type Specifications <br /> T r <br /> Domestic/Private )d Gravel Pack )4 Tracy yp of Casing� QType of out <br /> ' ["l Public C1gOther F1 Delta Depth of Grout Seal — z yp �- <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done _ <br /> Well Destruction 171Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADOITION l I DESTRUCTION I I (No septic system <br /> m per <br /> fe titled it public sewer is <br /> _ installation will serve: Residence`._Commercial - <br /> [ Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TAMC El Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal N <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1T1 Na. & Length of lines Total length/size <br /> r Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation p Y <br /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ h <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 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, I shall employ persons subject to workman's compensa <br /> ' tion laws of California." <br /> I The applicant ust cat]for all requir inspecti S. Complete drawing on ry4erse slde. <br /> o <br /> Signed X Title: ��- fl � - Date: <br /> ' <br /> R DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> �'�"L'"� <br /> Ie Data I� Fina! Inspection by Date <br /> Pit or Grout Inspection by 1I <br /> Additional Comments: 0-1�1 f D Id we( as s� Aa(� l J CQSI <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ M teca B23-7104 ❑ Tracy 835-6385 <br /> 11 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMC?!INT REMITTED CASH RECEIVED 9Y DATE ' PERMIT'NO. <br /> INFO <br /> ♦.EH 13-24(14 EV.I/x 51 <br /> EH 14-28 - <br /> s' <br />