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i <br /> APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN�LOCAL`HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-678T <br /> PERMIT EXPIRES VYEARTROM 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 /> made in compliance with San Joaquin Cdunty Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryies and Regulations of the San Joaquin <br /> Local Health District. �: . 1 .. - <br /> . . <br /> Job Address pity 5� ot Size <br /> PM <br /> Owner's <br /> Add <br /> Name ��Z^ ZULU[ <br /> ` Address - Phone7 <br /> f Contractor Address 31f�d f`'�af�C''rGF <br /> :L(cense Na Phone6T 761_0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R a OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IFfCATIONS_ <br /> i <br /> ❑ Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation Dia. of Well Casing l <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r I Type-of Casing Specifications <br /> ED Public ' <br /> ❑ Other � ❑ Delia t DepthFof Grout Seal � <br /> •- Type of Grout <br /> ll Irrigation ---Approx. Depth El Eastern Su"rfac_a Seal Installed by i <br /> Repair Work Done ❑ Type of Pum i <br /> p f H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter �5eating,Materi6_('top 50') <br /> Depth t=iller Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ;REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other r <br /> Number of living units: Number of bedrooms �° 1 <br /> Character of soil to a depth of 3 feet: Water tab depth <br /> SEPTIC TANK ❑ Type/Mfg Ca acit <br /> p Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ i r Method of-Aisi oral f <br /> Distance tonearest: ;Well Foundation Property Line <br /> a A- <br /> LEACHING LINE ❑ No. & Length of lines Total length/size# D f <br /> FILTER BED El Distance toynearest: Well Foundation Property Line <br /> SEEPAGE PITS � ❑ "Depth Size. Number <br /> SUMPS ❑ Distance toll <br /> nearest: Well Foundation Property Line F <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be clone-"i'naccordance 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: certify <br /> "I cert( that in theperformance of'the work for which this permit is issued, I shall not i <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 c ify 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 must f all req `ed in c' ns. Complete drawing on reverseis de. � <br /> 1 <br /> 'Signed' Title: �9. �� ��. <br /> Date: <br /> FOR DEP TMENT USE ONLY ' <br /> Application Accepted by 4-111,11' Date <br /> rea l <br /> Pit or Grout inspection by f Dat('- .Finafanspection by. D 85 <br /> Additional Comments: V , <br /> �tk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant- Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a <br /> FEE AMOUNT DUE AMOUNT REMITTED CK#__7 RECEIVED BY <br /> INFO CASH DATE PERMIT"NO. <br /> Y!� <br /> + EH 13-241REV.1/B5) - <br /> EH 1426 ' <br />