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t � <br /> . APPLICATION FOR PERMIT <br /> SAN :IOAQUIN LOCAL HEALTH DISTRICT <br /> -� 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 <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 /> f. made in compliance 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 Distric!?�53 ` § 'r <br /> Job Addre !a'1 - - F _ City Lot Size -IrisM� <br /> Owner's Name U, Address km E, Phone <br /> Contractor ddressC icense No. 30 Phone s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ri_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> e ❑industrial ❑ Open Bot®rrm' ❑ Manteca. Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy k Type-of-Casin Specifications <br /> ❑ Public ❑ Other , ❑ Delta Depth of Grout Seal X <br /> ';r `•, Type of Grout <br /> 0 Irridation --Approx. Depth—.,❑ Eastern .- Surface Soil..lnstafled by <br /> `1 RepairWorkDone ❑ Type of Pump H.P. ' State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION RUCTION ❑ (No septic system permitted if public sewer is <br /> available within 10 feet.) <br /> i" Iristallation will serve: Residence commercial- -Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f Water table depth <br /> } SEPTIC,TANK S Q. Type/.Mfg_ Capacity i �. No...Compartments <br /> PKG. TREATf1AENT.PLT.=p; s <br /> y Method of Disposal <br /> Distance to'nearest: Well Foundation Property Line <br /> *`I. LEACHING LINE "& Length of lines .— Totah�length/size 9 <br /> FILTER BED ❑ Distance to'nearest: Well"—.-.Foundation ZD�z " Property � <br /> P rty Line 6--` <br /> SEEPAGE PITS' ❑E•-Dt;pth I <br /> Number: r. i <br /> 15 SUMPS "" ❑ Distance to nearest: Well Foundation Property Lihe� <br /> F DISPOSAL PONDS El <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 /> _4 rules and regulations of the San Joaquin�t:oca(-Health .:h-District -^--� <br /> Z;4 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 manner as to become subject to workman's compensation laws of California.,,Contractor's hiring or sub-contracting signature 1 <br /> certif he 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, California." <br /> e applican s all for L_requi dins ions, plat dr wing on re rse side r <br /> Sign <br /> Title: Dater <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepleoby cwt `I Date Area <br /> Pit or Grou nspectioray /'t' Oat T <br /> Final Inspection by //r• ane � cj <br /> Additional Comments: <br /> --*^--+-^^C•d-Stk=466=678i-•-•-�--p-L-odi�-36,9-3621—�© Man#eco-823-:7104—.�p-Tracy"� ,� _. <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 H Rzn <br /> DATE PERMIT''NO. <br /> r <br /> EH 14-28 <br /> f U -3/4 <br /> s S`�-�7 <br />