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APPLICATION FOR PERMIT ' " ,n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZEL T ON AVE., STOCKTON, r�/ F <br /> Telephone (209) 466-6781 �`ppd//� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS ITE�121 <br /> (Complete in Triplicate) ,/ ,lr� . a <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'es ribeAhis 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 /> 3 ��5 e 16NT i'�tL� � � <br /> Job Address • _ CityLot Size PM <br /> I <br /> r Owner's Name—::SO )n�14 � r Address 3 J e ELGL�— �{ e, Phone Lr)3,3 <br /> Li <br /> Contractor !3 U AL Address License No.o 05 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> s <br /> IaUMP 1-NSTALLATION O —SYSTEM REPAIR UrtH­rA <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD. PROP. LINE( <br /> FOUNDATION'— AGRICULTURE WELL OTHER WELL PITS/SUMP,S _ <br /> INTENDED USE TYPE-OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> ❑ Industrial ❑ Operi Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 3 <br /> . Domestic/Private ❑ Gravel Pack i l Tracy Type of Casing Specifications � 44r_ ublic n Other�-----. n Delta Depth of Grout Seal Type of Grout _ <br /> 00 <br /> I I rigatlon Approx-Depth-i-Eastern-=--�- --=Surface-Seai-Installed by <br /> epair Work Done ❑ r Type of Pump __--.Ca, H,P. 3 -State Work Done <br /> Ul <br /> Well Destruct on ❑ Well Diameter �� Sealing Material Itop 50'I 3 , —__ <br /> —Depth 'ller-Material-Metow-50'f <br /> k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l 1 DESTRUCTION I I (No septic systerti permitted if public sewer is <br /> f "k available within 200 feet) <br /> !ti <br /> l Installation will serve: Residence_ .Commercial_ Other I <br /> Number of living units: Number of bedrooms f ' <br /> Character of soil to a depth of 3 feet: 1 INFLr table depth <br /> SEPTIC TANK ❑ Type/Mfg . CapacityfSNo\Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal k <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 Cl Depth Size Number <br /> I <br /> I p �JJJ <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line t <br /> DISPOSAL PQNDS - <br /> 1 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 /> l rules and regulations of the San Joaquin Local Health District. :,6 <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 /> r. employ any person i�,elcertify <br /> uh manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followin 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 ofC ! <br /> The applicant us all for all require spection . Complete drawing on revs se side. <br /> A <br /> Signed X Title: Date: <br /> IU <br /> I F R D ARTMENT SE ONLY <br /> Application Accepted by Date ! r Area 4 P <br /> Pit or Grout Inspectio by —Date"' , Final Inspectionh Date <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK if <br /> INFO AMOUNT DUE f AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> r QG <br /> s.EH 13-24 1REV.i/H 51 � ml�- <br /> r EH 14-28 r_l j� <br />