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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> I' 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' f <br /> *� <br /> C3 2-5-,3 I O c w"v V CityLot Size PM <br /> - <br /> i �, +rs r4 ss Phone <br /> Owner's Name <br /> IlCkAlt4..:� !Address 91(Actn4f r License o. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL - / WELL REPLACEMENT ❑ _01 DESTRUCTION ❑ <br /> j PUMP INSTALLATION�1/ SYSTEM REPAIR OTHER Lll t N_�_ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES ; DISPOSAL FLD.'� PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL ! OTHERWELL _.._ 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 /> RIJ <br /> ft ❑ Domestic/Private Ll Gravel Pack Cl Tracy Type of Casing Specifications <br /> F-I Public n Other F1 Delta Depth of Grout Seal Type of Grout-- <br /> I <br /> rout I I Irrigation .-Approx. Dept i I - tern S ace Seal Installed by <br /> Repair Work Done �e of Pump _ 1� H.P. . State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> I Depth Filler Material (Below 50') <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION i.) REPAIRIADDITION I l DESTRUCTION I I (No septic system permitted-if jiubliwer i§ <br /> f , available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms - A r + <br /> Character of soil to a depth of 3 feet: `" T g Water table depth <br /> SEPTIC TANK ; ❑ Type/Mfg 'r r Capacity No. Compartments <br /> k PKG. TREATMENT PLT. LlMethod of Disposal <br /> a <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ? ❑ Na. & Length of lines - -_ Total length/size <br /> FILTER BED ❑ Dunce to.nearest: �r Well Foundation Property Line <br /> SEEPAGE PITS I ] Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> r ­DiSPOSA&PONDS----❑ <br /> I hereby certify thatI 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`Jdaquin Local Health District. � <br /> Homeowner or-license egt3nt`s_signatdre cortifies the following._(eriify that in the performance of the_work for which this permit is,issued, !shall not <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 follow-ng: "I certify that' e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of lif nia. <br /> The appliCar, m t f all r quir�d s ct ns Com to drawing o re da. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 10A U"� Date ! Area <br /> �]�� <br /> 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 /> p licant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE ...,AMOUNT DUE AMOUNT REMITTED CASH P-35-6 <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24(REV.t/H 5) `i �`� <br /> b EH 14.26 ,` <br />