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APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.; STOCKTON,•CAS _ <br /> Telephone QW) 466-6781 8 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH I <br /> t (Complete in Triplicate) PERMIT/SERVICE=S <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 LR } <br /> aLn . / C <br /> Job Address r City r ✓ s Lot Size PM F <br /> Owner's Name )N Address Phone <br /> 4 <br /> r <br /> Cuntrao or Address C7 h:t/c. / License No. r L Phone 3 <br /> TYPE OF WELL/SUMP: �. WELL REPLACEMENT . DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR`Li OTHER ❑ r <br /> D S +ANCE TO NEAREST: SEPTIC TANK F -v0NE91INES �* _ DISPOSAL FID. PROP. LINE <br /> "' - FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS I0 <br /> /INTENDED USE! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECtFICATION476 <br /> 1 <br /> ❑^Industrial Open Bottom ❑ Manteca .Dia. of'Well Excavation Dia. of Well Casing <br /> I �. .w , 1 <br /> 7'� omestic/Private: ❑ Gravel Pack ❑ Tracy 4 Type of Casing Specifications <br /> 7❑ Public ❑ Other ❑•-Delta �C Depth of Grout Seal ! Type of Grout <br /> /❑ Irrigation 4, __. Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Material ItoI t <br /> Well Destruction �El Well Diameter Sealing Matep 50'1 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> C $� <br /> 11—K <br /> K f I available within 200 feet.) t� <br /> Installation will seive: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms ° 4 <br /> '`Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line 5 <br /> NIV <br /> LEACHING LINE I No&Length of lines Totaf length/size <br /> FILTER BED '❑\Distance to nearest:- Foundation I Property Line <br /> N4 it I <br /> hh <br /> SEEPAGE PITS ❑ D pth Size 7 _._.. TNumber <br /> i e <br /> SUMPS ❑ bistance to nearest:'_£ We I Foundation Property Line ; <br /> 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. <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 iri 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus � I for all r iredlPolotrions. Complete drawing on reverse side. <br /> fSigned1'71,�-4_--� Title: Date: <br /> FOR DEPARTMENT �USE ONLY (� <br /> • t` t . `.. r Date I Ala �/� 1 <br /> Application Accepted by l� Area �� <br /> f t <br /> Pit or Grout Inspection by Date "7 Final Inspection by Date X23 i <br /> Additional Comments: 8y y <br /> ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 823-7104 ❑ Tracy 8354M <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 SY DATE PERMIT`NO. <br /> INFO CASH <br /> + EH 13-241REV. /a5) —7O <br /> EH W29 E ipR <br /> i <br />