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b � <br /> i <br /> APPLICATION FOR PERMIT <br /> q <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in.Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or`instail 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 Lot Size PM <br /> Owner's Name i5C_5� Addre Phone <br /> Contractor 22,��+%�Address�� -" _ --License-No:C �i�t Phone <br /> Urso`, <br /> _ ; Phone <br /> TYP__ OF,WELL/PUMP:..-- __.--_---NEW WELL` 'Cl _WELL REPLACEMENT ❑ DESTRUCTION ❑' t o <br /> PUMP INSTALLATION ❑ * : ' .SYSTEM'REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTI SEWER,LINES POSAL FLD. PROP. LINE <br /> FOUNDATION` "i` ' RE.WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF PROBLEM AREA C TION SPECIFICATIONS <br /> _ ❑ Industrial ��-�" pen Bottom ❑ Manteca Dia. of Well Excava F Dia. of Well Casing <br /> ❑ Domestic - atm e ❑ Gravel Pack ❑ Tracy Type of Casing Spec cations <br /> �0111uigbllltci. <br /> ❑ Other i ❑ Delta �� Depth of Grout SealType utf ,i�Approx.,Depth ❑ Eastern .,.4 Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump' H.P.`j State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') 1,7 <br /> 1i r <br /> Depth Filler Material iBeiow_50']' *.`4�"TYPE OF SEP TIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION-0 (No septic system permitted if public sewer isavailable within 200 feet.) f <br /> Installation i vill serve: Residence 'Commercial_ Other. ,< <br /> Number 4living units: � Number of bedrooms <br /> Character of soil to a depth of 3 feet: .' s Water table-depth F <br /> SEPTIC TANK ❑ Type/Mfg __;CapaciNo. Compartments <br /> PKG. TREA MENT PLT. ❑ i IT . �? <br /> $ r �- Method of Disposal Distance to nearest: Well .Property Line <br /> Foundation <br /> LEACHING LINE No. & Length of lines � � Total'Iength/size U F I <br /> FILTER BED ❑ Distance toinearest: Well Foundation Property Line <br /> ` j <br /> SEEPAGE PITS ❑ Depth Fes' Slze yl Number _o <br /> SUMPS T% Distance to nearest: Well 13a-r; 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 DisNicL_,� <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 law§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." 1 s <br /> The applicant must cal ` all�uiradctions. Complete drawing on reverse side. } <br /> Signed Title: Date: —_- <br /> �- <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' Date Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by a Date ' <br /> t I i <br /> Additional Comments: I ! <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Applicant--Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE y AMOUNT AEMITTED JCASH~ RECEIyEI}BY -DATE `„ RMIT NO. <br /> + EH'13;241REV:'iY'i351 VW <br /> - <br /> f <br /> 'EH 14-26 Di f- "' s_ - 17WT7 <br />