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APPLICATION FOR PERMIT E V ED), <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT R E <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA U2 <br /> Telephone (209) 466-6781 ENVIRONIVIENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PEW /SERVICES <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 /> 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 /> t Local Health District. <br /> Job Address r City Lot Size F PM <br /> Owner's Name L!r � Address � ,�Qf/�-- Phone 11 <br /> r .2*72 <br /> s_y� r <br /> Contractor Oddress <br /> S � se Nor-�__ 17 Phone 6 6 <br /> TYPE OF WE PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR IX OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELt PITS/SUMPS <br /> ' -rINTENDED-USE'S' --�-TYPE-&.WELL­�PROBLEdA=AFiEA-2-CONSTRUCTION'SPECIFICATIONS - � <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic I Private LI Gravel Pack ❑ Tracy Type of Casing Specifications 1 — <br /> Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout j <br /> AIrrigation __.Apptox. Depth 4'I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Djq QcVfZ H.P. 1 .5-- State Work Done jv <br /> A. Well'b_estruction ❑ Well Diameter Sealing Material (top 50') 9- <br /> t Depth Filler Material (Below 501 <br /> I '^ <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <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 t 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 ❑ No. & Length of lines Total length/size <br /> FILTER BED _ ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth ^ Size _ Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ " <br /> --r hereby-certity:that I have prepared'-this appficatiora'and'th-at he-wb�k will=6e done"in accordance with�San Joaquin cbuniy ordinances, st a laws, and <br /> rules and regulations of the San Joaquin Local Health District. h y ' (f <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." Contractors 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 workm_an's•compensa. <br /> tion laws of California." <br /> The applicant must ca or ail required inspections. Complete drawing on reverse side. <br /> Signed X € - Title Date: 90— <br /> - F ` <br /> F R D=RTMENT SEO LYDate � a �` <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection b pate . <br /> Additional Comments: T <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7144 ❑ Tracy 835-6385 <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 BY VATE PERMIT'NO. <br /> INFO CASH <br /> r. , <br /> EH 13-24(REV.I H 5) r' � <br /> EH 14-28 III��� <br />