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rP 7 . <br /> 1~ a APPLICATION FOR PERMIT <br /> �J SAN JOAQUlN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON "AVE., STOCKTON, CA <br /> r` C Telephone'{209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED; <br /> {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 /> E made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. "' 4 <br /> Job Address 'err- � .� . . <br /> City Lot Size {` PM' <br /> Owner's Nam + <br /> Address Phone G - n � <br /> 26 gin <br /> Contractor Address It License NoAAIn IQ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC MENT ❑ DESTRUCTION '❑ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Z' OTHER ❑ <br /> DISTANCE TO NEAREST_: SEPTIC TANK--.SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications \ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern urface Seal Installed by <br /> Repair Work Done ' Type of Pump H. <br /> --� State Work <br /> I <br /> Done <br /> Well Destruction ❑ Well Diameter_ Sealing Material (top 50') , A ", O <br /> Depth Filler Material,(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAtR/ADDITION ❑ :DESTRUCTION ❑ (No septic system permi"sewer <br /> (. <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: # I f <br /> _ Water table <br /> depthSEPTIC TANK ❑ Type/Mfg Capacity No. CompartmentsPKG. TREATMENT PLT. ❑ iMethod of Disposar <br /> Distance to nearest: Well Foundation yx Property Line <br /> LEACHING LINE ❑-w No. & Length of lines- ---- - '- --- Total IengthYsize a - - t . <br /> FILTER BED LlDistance to nearest: Well -F= Fou.nda`�ion Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> -SUMPS---;;-- -�=�.-p,.;,Distance-to-nearest­;—. :Wel{. -- .Foundation "' = - Property-Eine -- - <br /> DISPOSAL PONDS ❑ <br /> 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 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." F <br /> The applicant m stt ill II required inspections. Complete drawing on reverse si e. <br /> Signed _ Title: _jvla _ llu <br /> Date: �. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date A3S 0 ~ Area <br /> J <br /> Pit or Grout Inspection by Date Final Inspection by Date �UUU <br /> Additional Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 1426(REV,t/65) �, •.�� ,. -i l .. �� <br />