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2 APPLICATION FOR PERMIT <br /> tip <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <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 /> A{wnah4nc� lrnn�no� eCClW/fi�'����6/7U��!'>>lipi City O -Si e Zr,ol PM <br /> Job Address ■�•u� .�. • <br /> 4�ood9• �sZ6—i�111 <br /> Address <br /> Owner's Name r"' rr1 Phone <br /> Contractor 3 � ���Ltyl Address234A 7`verb A License No.Tri. �Phone����sr1�' � <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � <br /> PUMP INSTALLATION 71 SYSTEM SYSTEM REPAIR ❑ OTHER V'Geoe i- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of�lA__e Excavation Dia. of Well Casing `\ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofCasir Specifications <br /> hote <br /> Type of Grout ,. <br /> Depth of Grout Seal YP <br /> FI Public Cl Other F1 Delta p <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Wk D�o�ne/�_ 1 1 <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 50') t aig 14 i 60 tnt O✓ � d t��1 ` }� <br /> Depth _yep �� Filter Material (Below 50.1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <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 ❑ Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING L 9 <br /> UNE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line—_�1N ENT r`%A <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ SAN JOAQUIN COUNTY <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with NR V Le.yaws, and <br /> rules and regulations of the San Joaquin Local Health District. UN <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 /> workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to <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 applica must call r a re wired inspections. Complete drawing on reverse side. <br /> , <br /> ' Signed X Title: �.�1 �� Date: &Kem <br /> OR PARTMENT USE ONLY <br /> � ? <br /> [ Application Accepted by Date a <br /> ,! Pit or Grout Inspection by Date Final Inspection b Date�� -4 <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ 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, Silk., CA 95201 <br /> ? IFEE NFO AMOUNT DUE AM UNT REMITTED C RECEIVED BY T(d��DATE PERMIT'NO. <br /> ♦.EH 13-241REV.t/s1S1 I CV— " <br /> EH 14.28 •? I R, y <br />