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APPLICATION FOR PERMIT <br /> --- �. SJOAQUIN LOCAL HEALTH DISTRICT <br /> - 1601 E. HAZELTON AVE., STOCKTON, CA ; <br /> Telephone 52091 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> —X s (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 /> 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 /> F <br /> Job Address - 1")DRAb 0 CityRv+``� Lot Size N � PM <br /> Owner's Na ---I Address 151Phone <br /> g 3s' s <br /> -41 <br /> t. <br /> Contractor T� ( It Address F •0 I &C < Licsse No 357 � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP,INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK '"". SEWER LINES", DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM A� <br /> REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Dj Open Bottom ❑ Manteca Dia. of Well Excavation t. r Dia. of Well Casing <br /> ❑ Domestic/Private ❑,Gravel Pack ❑ Tracy ([,",'Type of Casing Specifications <br /> M Public Other " 171 Delta '"' " Deth of Grout Seal <br /> -p Type of Grout _ <br /> I Irrigation --Approx�Depth l I Eastern _- u� urface Seal Install'.d by f t _ <br /> Repair Work Dome D Type of Pumpw` F^ W H.P. State'Work Done <br /> r Well Destruction D Well Diameter Sealing Material (top 501) <br /> Depth -FillerJMaterial I8elow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION.I,I DESTRUCTION I I iNd septic system permitted if public sewer is IR <br /> F available within 200 feet.I (Vr AI <br /> Installation willserve: Residence,_'s CommercialOther "s fiht <br /> Number of living units: Number of bedrooms tv <br /> Character of soil to a depth of 3 feet: f` : Water table depth <br /> SEPTIC TANK 'V kType/Mfg apacityl No. Compartments <br /> PKG. TREATMENT PLT. ❑ F , '; _ l Method of Dispo al <br /> tg <br /> � Distance to nearest: Well�_ Foundation 270" Property Line � <br /> G !N n <br /> or 0 <br /> LEACHING LINE &,�No. & Length of lines Total length/size <br /> FILTER BED ❑ ; Distance to nearest: Well 310 Foundation 701 Property Line�� f <br /> SEEPAGE PITS I I :F Depth Size Number d <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - . -— — -i <br /> F 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 nner as to become su ' ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I rtify that in the pertor a 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 applic nt m c or all required i ctions. o et rawing on re side. ' <br /> Signed X Title: Date: I/w/Ir? <br /> r <br /> DEPARTMENT USE ONLY <br /> Application Accepted b'y Date Area— Yo <br /> Pit or Grout Inspection by "-`\ r" Date! `s Final 1pectian <br /> , b Date <br /> t Additional Comments: 47 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 V ❑Iracy 83 -6385 <br /> t Applicant- Return.all copies to: Environmental Health Permit/Services"1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE! E CK V­ <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> r <br /> + EH 13.2411 HEV.i/n a7 D t�Z7 <br /> EH 14-28 I 5- <br />