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_ - u� Y <br /> c Z 1 f`ro SPL 5 *< N t3o �a <br /> J4 (A,3, � APPLICATION FOR PERMIT <br /> W aCe SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br />© Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <br /> (Complete in Triplicate) <br /> Application is 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 com with San Joaquin Coun Ordinance No.549 for sew ge or N . 1 for well! um and the Rules and Regulations of the San Joaquin + <br /> Local Health Di s rict. - <br /> City Lot Size [O X /5- " PM �{� F <br /> Job Address f.J <br /> Owner's Name - v ' ddress Phone <br /> e + 1 <br /> Contractor/ Address T License"No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A y <br /> ,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' <br /> DISTANCE 70 NEARESTOPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FDUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYf 9 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ` Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp <br /> ?• � , T of Grout— <br /> Eq <br /> ❑ Public '❑-Other ❑ Delta Depth of Grout Seal Type , y <br /> 1 L Irrigation �pprox. Depth ED Eastern Surface Seal Installed by <br /> Repair Work', <br /> El Type of.Pump State Work Done— <br /> Well Destruction ❑ Well Diameter f. Sealing Material {top 50'1 ' I <br /> Depths Filler'MateriallBelo 50'1 <br /> TYPE OFiSEPTIC WORK: NEW INSTALLATION�j;REPAIKIADOITION DESTRUCTIO a ti system permitted if public sewer is <br /> i1A within 200 feet_! s <br /> Installation will serve: Residence, Commercial_ Others ..�-\�' �r" -`-�++ f " <br /> Number-ofliving units: Number of bedrooms <br /> Characte soil to a depthfiof `feet: , Water table depth " <br /> SEPTIC TANK LJ' Type/Mfg r Capacity No_ Compartments q \" <br /> ' € Method of Disposal T " <br /> PKG'TREATMENT PLT. ❑ �l ��' <br /> Distance to nearest: Well �6/y Q-Foundation Property Line <br /> LEACHING LINE t No. &'!Lei gth of lines otal length/size <br /> FILTER BED ❑ Distance to nearest: Weil 11/ -Foundation Property Line ' <br /> SEEPAGE PITS " O Depth Size Number � 1 <br /> SUMPS ❑"'Distar,a to nearest: Well�� "Foundation_ roperty Line <br /> DISPOSAL PONDS ❑ w <br /> . Y <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. s <br /> Home owner br licensed agent's signature certifies the following: "I certify that in the performance'of.the work for which this perm 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 /> I 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 /> f tion Yaws of California." 19 <br /> The applicantlmust call for all r quired ins ctions. Complete drawing Jrrev��e.sid a. I <br /> Signed Title: <br /> FO DEPARTMENT USE ONLY <br /> L <br /> •+ Q, Area d <br /> Application Accepted by �$ Date s <br /> Pit Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 1 <br /> ❑ Stk 466.6%80 "ED"Lodi 369-3621_,I ❑,Manteca,,..823:7104"._...:-_❑Tracy--835-6385-------•^"'y"'"`"""'""'"""' <br /> r. Applicant- Return all copies to-t Environmental Health�PermitlServices 1601t,E. Hazelton Ave., P.D. Box 2009. Stk., CA 95201 <br /> 3 <br /> FEE AMOU'N'T DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> WO //�� CASH <br /> f + EH 13-24(REV.1i85) F-_7[J' 00 <br /> EH 1418 <br /> I <br />