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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> li PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> application is <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 app'l <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 /> w <br /> Job Address City Lot Size PM <br /> Address ' Phone <br />'f Owner's Name <br /> E Contractor &)ENIZ_* P%LA-_ - AddressD License No. 3O Phone <br /> 7G <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 /> i 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 /> ED Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ['1 Public 171 Other ll Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by - <br />` Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 <br /> Depth Filler Material (Below 501 N <br /> t. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION - ESTRUCTION l [ (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Res' ence t Commercial—+ Other <br />° Number of living units: Number of bedrooms 21 <br /> i Character of soil to a depth of 3 feet: A ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: —Well Foundation-' Property.Line <br /> LEACHING LINE L+--Ifo. & Length of lines Total length/size <br />: FILTER BED ❑ Distance to nearest: " Well Foundation r Property Line <br /> J <br /> SEEPAGE PITS lq_-1Dre-pth -Size .-_ 23'2> Number L <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Id- ' 90 <br /> 1 <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, I shall not <br /> employ any person in such-manne�'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 a f Californi . 1. - <br /> The applicantiNt c 11 for II r iced i specti ns. o plate drawing on verse si <br /> �h r <br /> Title: _lam_ 1 _— Date. <br /> Sign - <br /> �. - FOR DEPARTMENT USE ONLY p <br /> c Date —?q tS Area <br /> i, Application Accepted by _ <br /> —. � _. -"=--..._- ,.Pit or or Grout Inspection by Date Final Inspection by 6 L Data ' <br /> ( Additional Comments: <br /> l ❑ Stk 466.6781 E❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> f 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` CASH RECEIVED BY DATE PERMIT'ND. <br /> r.EH13-241REY.I WINFO 0 C3. <br /> EH 14-28 <br />