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~ i APPLICATION FOR PERMIT <br /> SAN JOAQ_UIN LOCAL HEALTH DISTRICT <br /> ! 1601 E. HAZE'ITON\XI E , STOCKTON, CA <br /> Telephone�12091 466- 67$1 <br /> 3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> Application is heieby 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 /> Job Address �"" � Fill City Lot Size PM <br /> tfpid;ept C#4 <br /> Owner's Name AddressPhone <br /> ,_ ILtJ�L.e!Z�jp <br /> 'Contractor lelh �"AML rI ddtess © � L42 7 License No. M Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> }� PUMP INSTALLATION 113' SYSTEM REPAIR OTHER IJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE tTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca b � Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> .r, <br /> ❑ P blic I.1 Other 71 Delta 4,f Depth of Grout Seal Type of Grout---- ICJ <br /> i frigation — Approx. Depth stern S ace Seal Installed by r _ e-**Repair Work Done Type of Pump n� H.P �t� __ State Work DoneCA -.S <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> JOepth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/,ADDITION l 1 DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commerc' 1_ Other <br /> Number of living units: Number of bedroo "f". <br /> Character of soil to a depth of 3 feet: "•q t Water table depth <br /> J' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearestr We r 'foundation Property Line <br /> LEACHING LINE ❑." No. &-Length-of-tines Total length/size <br /> } ; <br /> FILTER BED ❑1 Distance to:Weare -" ;Well oundabon Property Line <br /> .mss. 4 r <br /> SEEPAGE PITS I i Depth Size Number <br /> I SUMPS ❑ :'Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I I:hereby certify that I haves 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 Di?;trict. <br /> Home owner or - nsed a is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> F employ any son in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies th ollowing:"I certi that in the rformance a work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion as f Cali rnia." ' <br /> The ap re nt st all re r mple n <br /> 7-Signl3 X <br /> FOR DEPARTMENT'US,E ONLYr-.-�,4. y 6 j -� J <br /> 'Application Accepted by Date Area <br /> Pit or Grout Inspection by I Date Final Inspection by ' -= Dat —Z"���% <br /> Additional Comments: j �I <br /> r ❑ 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, Stk., CA 95201 <br /> a <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> a.EH 13-24(REv.I/H5) co <br /> EH 14-26 1 <br />