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41 .. APPLICATION FOR PERMIT ' <br /> s �*' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> ! Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! <br /> r, (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ; <br /> Job Address City. e,<Te`.[/ Lot Size /Gi ere PM <br /> Owner's Name Address <br /> ? <br /> Phone <br /> - t <br /> . Corjtractor ZiAi E Address ^' L License No.1��Phone <br /> ,TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION jf SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKrel SEWER LINES DISPOSAL FLD. PROP. LINE «tel <br /> FOUNDATION AGRICULTURE WELL OTHER WELL SO / PITS/SUMPS Z,l7 r <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation_ " Dia. of Well Casing `� # <br /> Domestic/Private - OrGravel Pack ❑ Tracy Type of Casing 10 ti Specifications /G d <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal D Type of Grout C-eej \ <br /> ❑ Irrigation r <br /> 9 pw22—Approx. Depth ❑ Eastern Surface Seal Installed by <br />•� Repair Work Done D Type of Pump .511,6 H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material{top 501) <br /> Depth 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: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK; _ _ ❑ Type/Mfg_ Capaci _ w <br /> ;No._Compartments - <br /> PKG. TREATMENT PLT. ❑.^.- <br /> r Distance to nearest: Well Method of Disposal <br /> Foundation Pro <br /> Property Line <br /> LEACHING LINE 4 ❑ No. & Length of lines Total'length/size f r <br /> FILTER BED ❑ Distance to nearest: Well 4_ Foundation Property Line <br /> F [ <br /> SEEPAGE PITS ❑, Depth Size `` l Number f <br /> SUMPSell <br /> , ❑ '.Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 11 # <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 /> s rules and regulations of the San Joaquin Local Health District. i <br /> } <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 1l <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 /> sa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compenure <br /> tion laws of California." <br /> The applicant must call r all req_ ed inspec-ons late drawing on reverrssej side. <br /> Signed , Title: �J Date: _ 6 <br /> FOR-DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection y Datey <br /> Final Inspection bDate <br /> �. Z _ <br /> Additional Comments: <br /> ❑ 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 CK RECEIVED BY DATE PERMIT�NO. <br /> INFO <br /> + EH 1 -24(flEY.1/85) ` �S ^� <br /> EH 144-26 <br />