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APPLICATION FOR PERMIT , <br /> SAN JOAO.UIN`LOCAL HEALTH.DISTRICT-: p � 1 <br /> 1601 E. HAZELTON,AVE- STOCKTON, CA " <br /> Telephone-(209)",.4.66-6781. l 5 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) LNVIROMElN``TAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wkFP,'AIX eS9AVAC�%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 <br /> L City Lot Size .PM <br /> Owner's Name III A) � L�A Address ����` �a I.�(� Phone <br /> Vont ac� Ctrvl r° ! &6!V Address/Mk Ill, ,840nfi Y License No Phone <br /> I <br /> TYPE OF WELL/PUMP: NIEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR)<F 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 ❑ Mariteca Dia. of Well Excavation Dia. of Well Casing <br /> _ r <br /> iA Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a. <br /> 11 Public ❑ Other 11 Delta,: Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation —.Approx. Depth ( I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump _+ � H.P. %1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORKNEW INSTALLATION 1:1REPAIR/ADDITION I 1 DESTRUCTION i.1 (No septic system permitted if public sewer is <br /> : <br /> -..available within 200 feet.)- <br /> Installation <br /> eet.)•Installation will serve:' Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - Capacity " No. Compartments M <br /> PKG..TREATMENT PLT. ❑ Method of Disposal c� <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize - <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number T[� <br /> •.: SUMPS- Y . RLI=Distance-to nearest: ­'WellL 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 Jnaq,#n county ordinances, state laws, an� <br /> rules and regulations of the San Joaquin Local Health District. y <br /> Home owner or licensed a ant'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 ner as o ecome su to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following• "I c that' the'pe nc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Californi <br /> The applicant t far all d ' s ? Complete drawing on reverse side. <br /> Signed X Title: M IV Al/rC,:.� Date: <br /> r ; <br /> r 0 EPARTMENT USE ONLY l ( �p <br /> Application Accepted by Date b , Area <br /> I Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <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 /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-26 <br /> EH 14-2e IREV.1/8 s1 <br />