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5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> LTy ti�q�oAp 48`' <br /> (Complete in Triplicate) �Cpc,�9/ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thisa�i itlm is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Q <br /> Job Address ?[G iJi 6a-k ap�✓ (3~r(�, LLd City r 4ya Lot Size PM <br /> Owner's Name t /—ss o M Address -2027 /2Z1U T /k__ hone &2­7"&o.3Z5 <br /> Contractor's Name ' ���^' S��License No. "/�U!C� •Phone 2aa7 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> a t <br /> PUMP-INSTALLATION ❑ SYSTEM REPAIR Ik OTHER ❑ � 2 <br /> DISTANCE TO NEAREST: SEPTIC-TANK.— SEWER LINES—: DISPOSAL-F)_D �PROP,:LINE - � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 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 /> >,Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications, <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t <br /> ❑ Irrigation; # _, 4pprox. Deptha ElEastern Surface Seal Installed by <br /> Repair Work Done'� Type of Puma S� H:P. � + State Work Done F � <br /> Well Destruction ❑ .,Well Diameter _Sealing Material (top 501 5m U� <br /> r h <br /> Depth Filler Materia[ (Below 501 •'�r. l.� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ©. (No septic system permitted if public sewer is 7. <br /> 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 ,1 �❑ Type/Mfg Capacity 3 No. Compartments X44111"' <br /> PKG. TREATMENT'PLT: Eh � �:�a Method:of Disposal <br /> Distance to nearest: Well Foundation ' Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> n <br /> SEEPAGE PITS ❑ Depth Size Number <br /> E117 — <br /> C <br /> SUMPS ❑ Distance to nearest: Well r Foundation Property Line W �v <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 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 manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following. I ce that in the.performance of the work for which this <br /> " rtify permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant _. • t call f r all reqs d ' ctions. Complete drawing on reverse side. <br /> Signed Title: 40— Date: <br /> Date: <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �-' Area r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 46643781 ❑ Lodi 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED 0 H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24{REV.10183) <br /> EH 1428 1 /�" <br />