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P <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> �5 70-`�>1' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> t <br />€ (Complete in Triplicate) <br /> i <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. 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> g� <br /> Job Address 125 � � s � 1~e <br /> City- d' ize PM <br /> I Owner's Name f �f� (� Address 57 - 8 Phone <br /> y <br /> Contractor Adtlress -e-��t--III�Oe- License No. Phone —/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION R� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINT= <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [7 Public F1 Other- 17'Delta. Depth of GroutSeal Type of Grout <br /> 1)6 Irrigation ___Approx. Depth I ] Eastern Sutface Seal Installed by - <br /> Repaif Woik Done t -Type of Pump .__. `H.P. State Work'Done <br /> �� ^~ <br /> Well Destruction �" . Well Diameter �-t Sealing Material atop 50,1 4� } <br /> Depth t Filler Material (Below 501 �T` ­Fiae` -ar�.� <br /> e on <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION ( I DESTRUCTION i I Wo septic system permitted if public sewer is pu <br /> � 'available within 200 feet.) �J <br /> Installation will serve: Residence— Commercial_ Other r r <br /> Number of living units: Number of bedrooms . <br /> Ctiaracter of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ # d Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> r !n <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size r r Number. <br /> i SUMPS L] Distance to nearest: Well F Foundation r Property Line ' { <br /> "a <br /> f DISPOSAL PONDS ❑ <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." ,i a <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 <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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic st callforall require pectin omple rowing on re a side. <br /> Signed X v� 4 Title: �� S Date: <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> Pit at Grout Inspection b Date Final Inspection b Date, <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 /> kFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> +.£H 13-24{REV.I/A 5) *3,5 C- k <br /> EH 1488 <br />