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::APPLICATION FOR PERMIT , <br /> . SAN JOAQUIN LOCAL.HEALTH DISTRICT Np �� <br /> 1601 E. HAZEION AVE., <br /> ,STOCKTON,'CA NJ'O �0` <br /> -Teleph6ne,(209) 466-6781 P-"C_r;- �f l <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> ,-# .,4rs+ mry '_.. {Complete in Triplicate/ <br /> Application,i ,hereby made to the San Joaquin Local Health District-for a permit.to-construct and/or install the work herein describd_eThrs application is . <br /> f'; made in compliance with San Joaquin County;Ordiriance No. 549 for sewage or No; 1862 for well/pump and the-Rules and Regulations of the San Joaquin <br /> Local Health District." <br /> r Job AddressCi Lat.Size" %, <br /> v . <br /> Owner's Name � d e � � � � phos ' <br /> Contractor sS ��n`; <br /> se No: ! Phone <br /> y <br /> TYPE OF WEL / U P: NEW WELL' ❑ WELL p.: DESTRUCTION ❑ <br /> Ir <br /> PUMP.INSTALLATION ❑ ;i SYSTEM REPAIR-❑ OTHE n <br /> DISTANCE TO'NEAREST:-,SEPTIC TANK SEWER_LINES DISPOSAL FLD: PROP."LINE <br /> } FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS <br /> ' INTENDED USE . "-TYPE OF WELL PROBLEM AREA CONSTRUCTI 'ICATIONS <br /> ❑ Industrial ❑Open Bottom.. ❑ Manteca .° 'Dia. ell Excavation' Dia. of Well Casings <br /> ❑ Domestic/Private ❑ travel Pack . -❑ Tracy . ype of'Casing Specifications, <br /> r' +, <br /> ❑ Public L1 Other ❑ Del Depth of Grout-Seal Type of Grout <br /> ❑'Irrigation uApprox Depth Eastern, s� Surface Seal Installed by `' <br /> I Q <br /> - Repair Work DoneType,of H.P Stale Work Done <br /> Well Destruction a I.Diairmeter Sealing Material.ftop.50'1._ <br /> Depth '"` i' - Filler Material (Below 50'1`x, <br /> TYP SEPTIC WORK: NEW INSTALLATION ❑' REPAIR/A00ITJON ❑ .DESTRUCTION ANo•septic system permitted if public sewer is•'ILL <br /> -, <br /> availabIt <br /> le within 200 feet.) <br /> Installation will serve ,Residence"_ Commercial Other <br /> Number of living units--- Numberof bedrooms <br /> 3' -heracter"of soil to a depth of 3'feet k � - <br /> y Water table depth <br /> * ' SEPTIC TANK ❑ T e/hill $ 1 <br /> yp g Capacity No..Compartments <br /> PKG. TREATMENT-,PLT. ❑ s .. Method of Disposal <br /> t - <br /> ' r `Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE i,❑ No. & Length of lines r ` Total length/size <br /> ` FILTER BED ='. r Distance to'nearest: Well _`"` ''`= 'Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size _ Number s t <br /> x.r <br /> SUMPS -- ❑ Distance to,nearest:. ;Well -Foundation. Property Line <br /> .` DISPOSAL PONDS ❑ <br /> r {.,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, I shall not <br /> employany person in such manner as to become.subject to workman's compensation laws of California.”Contractors hiring or sub-contracting signature <br /> certifies the following:-"Lcertify that it the performance of,the work'for which.this permit is issued,I shall employ p"ns subject to workman's compensa- <br /> tion laws,of California."` <br /> i `Tho applicant • st` II for II r� inspections.,Co 'plate drawing o ver side. <br /> SignedY Title: ' ' r p <br /> i Date. R <br /> R DEPARTMENT USE ONLY <br /> A � �. <br /> Application Accepted try __ � y `1M �ymfl„wA� ��_-Date n `�� Are . <br /> Pit or Grout;Inspection by Date Final Inspection by Date a <br /> Additional Comments: <br /> ❑ Stk 466-6 81 ❑ Lodi 369-3621 ❑ Manteca .823-7104 w 0 Tracy 83x6385 <br /> Applicant- Retum all copies to. Environmental Health Permit/Services 1601 E.Hazelton Ave., P.O. Box 2009, Stk.,-'CA 95201 . <br /> i FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH- RECEIVED BY DATE PERMIT'NO. <br /> 1 <br /> + EH1H-24(REV i <br /> EH 14-26 <br />