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r.. .V was. <br /> APPLICATION FOR PERMIT r i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA I <br /> Telephone 12091 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 /> 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. <br /> Job.,Address J 5 OQD CittyLot Size PM <br /> Add <br /> CoVNwdT r �J r� _cs ; <br /> ess one <br /> I � S3S-� <br /> Contractor's Name cense No. Zgm Pho e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER'WELL 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 n4 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Q <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction. ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <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 I Residence— Commercial— Othe �� 4+w <br /> Number �dn:� Number of bedrooms LA <br /> Character of soil.to a depth of 3 feet:01 # "ater table depth <br /> SEPTIC TANK L Type/Mf Capacity o. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: , Well Foundation Property Line , <br /> (A <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property"Line O ; <br /> SEEPAGE PITS ❑ 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 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 ch manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the followin . '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 Califo <br /> The ap ils all for all requi T1s. Complete drawing on rev I <br /> Title. Date: <br /> FOR DEP RTMENT USE ONLY <br /> Application Accepted by )ateArea 4� <br /> �- <br /> -�,reepa�s cam' n b� Date— r�L Final n coon Date_ <br /> Adi3itidna�Comment� � � 7�g7 . <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 <br /> INFO. AMOUNT DUE OUNT REMITTED CASA RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 IREV,101831 _ $� y `- .- <br /> rEH 14281 1 l <br />