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APPLICATION FOR PERMIT r r <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i F Telephone (209) 466-6789 <br />! PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) .� <br />[ Application is hereby made to the San Joaquin Local Health District for a <br /> permit to construct and/or install the work herein described. Tf I applica#ion 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. �I <br /> Job Address 90q <br /> �. City Lot SizePM col <br /> �eCd <br /> Owner's Name O G <br /> Address <br /> on ract ame Phone 3 +%{ 11626 <br /> C r � - <br /> �8 N WELL `� <br /> TYPE OF WELL/PUMP; License IN Phone <br /> i WELL REPLACEMENT ❑ R <br /> PUMP INSTALLATION DESTRUCTION El REPAIR ❑ OTNEt ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S <br /> —�� SEWER LINES <br /> FOUNDATION "` - DISPOSAL FLD.-t <br /> AGRICULT" " THIEF <br /> PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS �l Od/ <br /> TYPE OF WELL PROBLEM AREA , <br /> ❑ Industrial CONSTRUCTION SPECIFICATIONS <br /> ❑ Open'Bottom ❑ Manteca Dia. of Wel! Excavation <br /> Domestic/Private f Dia. of Well Casing <br /> Grave! Pack ❑ 7rac <br /> ❑ Public ❑ Other! y Type of Casing ;�/ <br /> ❑ Delta Depth of Grout <br /> Seal f SD ' Specifications - <br /> ❑ irrigation I r <br /> Iq <br /> —_4pprox. Depth ❑:Eastern S rface Seal Installed by Type f Grout BP- - �. <br /> Repair Work Done ❑ T p �� Q/� /A/ �y <br /> Type of Pum H P i <br /> Well Destruction ❑ Well Diameter ,' State Work Done J ,( <br /> e Sealing Material{top 50') <br /> Depth 4 FilW-Material;{below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> Installation will serve: Residence I Commercial Other + available-withfn'200•feat-) _ l <br /> Number of living units: Number of bedrooms ~~- <br /> i <br /> Character of soil to a depth of 3 feet: I <br /> SEPTIC TANK ❑ Type/Mfg I r*. y Water table depth <br /> PKG. TREATMENT PLT. ❑ .-Ca0acity— No. Compartments <br /> ya <br /> �� N�IADfstance to nearest: Well Method of Disposal <br /> Foundation L=h <br /> LEACHING LINE 1❑ No. & Length of linesti/ Total leFfLTER BED ❑ Distance to nearest Well Foundation rtSEEPAGE PITS ❑ DeSize'SUMPS Numbe❑ Distance to nearest° Well' FoundationDISPOSAL PONDS ❑ - <br /> I hereby certify that have prepared this application and that the work'will be done in accordance with San Joaquin coup i <br /> rules and regulations`of the San Joaquin Local Health District. q _ Y �tY and n8ncel stat laws, <br /> -Homeowneror licensed agent's signature certifies the following: "I certify that in the performance of the work for_which this permit is issued, 1 shall noi.w , <br /> employ any person-in such manner as to become subject to wo?kman's•compensatiohAaws of California. Contractor s.hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this: iFmii is issued, I shall employ <br /> tion laws of California." p Y persons subjectto workman's compensa <br /> d ` <br /> 1The appl`ican 5 IL req 11 bns. Complete drawing'on rev side. # <br /> -r _ f <br /> Signed <br /> Date: I <br /> I FOR EPARTMENT USE ONLY <br /> Application Accepted by <br /> Date��., Area Zo <br /> Pit or Grout inspection by Date 5 <br /> Final Inspection by L"t� Date s <br /> �J D <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ odi 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 AMDUNT DUE!I AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> EH 13.24(REV.10183) <br /> EH 14-26 <br /> �I w <br />