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S ' <br /> &S, :..L► APPLICATION FOR PERMIT j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 UUU <br /> PERMIT EXPIRES 1 YEAR 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 /> 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 / City —J/A_ 4 Lot Size PM <br /> Owner's Name Address S,4A1, -� „ . Phone% '�0' <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ATION AGRICULTURE WELL OTHER SJSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A ION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Man Dia- of Wel on Dia. of Well Casing p <br /> ❑ Domestic/Private C Gravel Pack Tracy Type of Casing Specifications <br /> ('1 Public n Other ❑ Delta Depth of Grout Seal y rout _ <br /> I I Irrigation pprox. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> \`\ Well Destruction ❑ Well Diameter Sealing Material Itop 50') X11 } <br /> Depth Filler Material !Below 50'I <br /> 1, TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br />`x1,11 available within 200 feet.) <br /> 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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: WelFoundation Property Line !I <br /> M <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well 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 Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diktrict. <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 manner as to become subject to workman's compensation laws 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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c I r all required i s ctions. Complete drawing on reverse side. / <br /> SignedtitY' Title��'�t�a�b �rc.Ly7'L/ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 'i.21�_PID 5 <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> � ~ Za+ EH 3-21(REV.1rn5) � 77u <br /> b� �,7V -1-5 <br /> r <br /> EH 14-26 ((G� <br />