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} <br /> '• -- .. - APPLICATION 'FOR`PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 5 (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 /> I 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 Joaq 1. <br /> { Local Health District. <br /> 1 t ' <br /> Job Addressx a� °+ <br /> City Lot Size PM ' <br /> . CtiO . 67 <br /> wner's Name Address ` `''`' ^� } �`t l' X63_ O�► <br /> Phone <br /> ,Contractor's NameAr- /10 <br /> h <br /> License No. / Phone t/44 <br /> j <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 1 DESTRUCTION ❑ W <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK'_ SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELD 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T W <br /> ype of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by —i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 -� <br /> Depth Filler Material (Below 501) 1, ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet./_ <br /> Installation will serve: Residence Commercial_ Other ' f <br /> Number of living units:' Number of bedrooms/ a <br /> Character of soil to a depth of 3 feet: C Water table depth <br /> SEPTIC TANK ❑ Type/Mfg &&=qCapacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Welyo�oundation "Property Line <br /> a <br /> -y r <br /> LEACHING LINE No. & Length of lines Total lefgth/size <br /> FILTER BED 13 Distance to nearest: Well Fou dalon__ / Property Line _ <br /> Gl awl l C {, c %e� i <br /> SEEPAGE PITS 0_,Depth _ Size Number <br /> SUMPS ❑ Distance to nearest: Well 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 th'e following'l'ce�r ify tKgt tri the performance of the work for which thissA <br /> employ any person in such manner as to become subject to workman's compensation permit is issued,"I shall not <br /> h <br /> .- pensation 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." J <br /> The applicant must call for all requi spections. Complete drawing on reverse side. " <br /> Signed X— <br /> Title: Date: I' <br /> � FOR DEPARTMENT USE ONLY .• <br /> Application Accepted by - Lil�/� �--- <br /> Date - T /k^4 y Area <br /> Pit'or Grout Inspection by/ Date Final Inspection by Date <br /> �� <br /> Additional Comments: zV.,4, 1v <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 -'0 Manteca. 8234104 ❑ Tracy 8354G%, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.- Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> r <br /> INFO AMOUNT DUE " AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 1}24(REV <br />� EH 1b26 LJl . <br />