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APPLICATIDM-FCR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> �. "` ja.,� d (Complete in Triplicate) ` rs <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 /> rliiade 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 /> t `*" } t:a , ^, araC.. -• � .. <br /> Job Address 4n79-0 City Lot Size PM <br /> Owner's NameL ,G �� �� Address-/�� Q/J� Phone <br /> Contractor'- Address t ; License No. 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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION ❑ DESTRUCTION ❑ (No-septic-system.permitted if public sewer is <br /> av table within oo f_Vt.) s - - <br /> Installation will serve: Residence._X Commercial_ Other <br /> Number of living units:_�_ Number of bedrooms <br /> � . <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK J Type/Mfg '` Capacity�Gb No. Compartments <br /> PKG. TREATMENT PL-T. ❑ .,.�.,,,,; _ •bx-= Method of Disposal <br /> f Distance to nearest: Well oundation /Q' Property Line Lr <br /> LEACHING LINE ❑ No. & Length of lines:'} '° a TotaVfength/size <br /> FILTER BED ❑ Distance to nearest: Weft Foundation Props" Line <br /> SEEPAGE PITS ❑!,Deptti� rZ S Size �, .D ` bar -D # <br /> � � S� N y ► <br /> SUMPS ❑ Distance to nearest:— 'Well / Foundation_��_-.. Property Line <br /> DISPOSAL PONDS.. ❑ { i i �;p+.{ .•.--. f <br /> hereby certify that f-Piave 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."Contractor's hiring or sub-contracting signature \ <br /> certifies the following:'.'4 certify that in the performance of tie'work for which this permit is,issued,I shall employ persons subject to workman's compensa- <br /> -tion laws of C 'o 'a" r J� <br /> The appli st?cal or r ins pe . Complete drawing on reverse side. <br /> Signe Titla w Date: <br /> r � <br /> FOR DEPARTMENT USE ONLY y <br /> n Accepted by Date Area <br /> S <br /> Cpl!it7or ��o <br /> ut Inspection by ate Final Inspection by sun.,n Date <br /> A ditional Comments: } tr <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 <br /> fA&Iicant- Return ail copies to: Environmental Health Permit/Services 1601E Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE' <br /> AMOUNT DUE AMOUNT-REMITTED�°- RECEIVED BY DATE PERMIT`NO. <br /> INFO 1 CASH <br /> + EH'13.24(K-fv.i/e5) .� I�.0U:. _ _�$`� —j��I""" <br /> EH 1426 lJ <br />