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k \, <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZELION AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <br /> � 6r/ PERMIT EXPiRES I YEAR FROM DATE ISSUED Y <br /> � y� , (Complete in Triplicate) <br /> Ap kation 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 /> t r <br /> Jab Address <br /> 8 14/ UE " <br /> Ci Lot Size PM <br /> Owner's Name- e Address 41 0 <br /> Phone -« <br /> Contractor S r Address. 3S � 1%i .,License r' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ L <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 <br /> ,,,. •M_-.-. •� Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Public Specifications <br /> C7 Other",`,L,.i —�. ❑ Delta Depth of Grout Seal r <br /> ❑ IrrigationType of Grout <br /> _ <br /> pprox. Depth,❑_Eastern Surface Seal Installed by <br /> Repair Work Done 1) Type of Pump �^'`A P. _ State Work Done a <br /> Well Destruction ❑ Well Diameter dealing Material (top 50') <br /> Depth Niler,Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTIOUXRE(No septic system permittedif public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_Other, <br /> Number of living units, Number of bedrooms.r , <br /> Character of soil to a depth of 3 feet: # 4 <br /> Water table depth <br /> SEPTIC�TANK -.,� ❑ Type/Mfg j <br /> No. <br /> Capacity <br /> p� <br /> P Compartments l <br /> PKG�REATMEN ' tYPLT. ❑ h ` 1 <br /> Method of Disposal <br /> Distance to nearest: W"Well Foundation Property Line <br /> LEACHING LINE O W. & Length of lines Total length/size <br /> FILTER BED ,_. <br /> ❑ Distance to nearest: Well Foundation. Property Line <br /> SEEPAGE PITS Cl 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 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 workman's compensa- <br /> tion i <br /> tion laws of Calif nia." 1 <br /> The applicant u call for all required inspectio s. Complete drawing onr rserse rA e. <br /> Signed <br /> bate• <br /> FOR pEPARTMENT USE ONLY ,� <br /> Applic on Accepted by <br /> Pit <br /> Area <br /> Pit or Grout Inspection by <br /> AU74 Date Final Inspection by Date <br /> Additional Comments: AID —e rVVIJ[ i <br /> ❑ Stk 466-6781 11 Lodi '369-36211' CA <br /> ❑ Manteca 823-7104 ❑ Tracy 835 6385 ,` S <br /> Applicant Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 5 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO C RECEIVED BY - DATE PERMIT N0. <br /> EH 24(REV-„B 5) /-b <br /> W <br /> ' EN 74-29 <br />