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APPLICATION FOR PERMIT Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> W PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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. W eL>fl <br /> r=J, <br /> f i <br /> Job Address City Lot Size PM <br /> cnp <br /> Owner's Name dress Phone <br /> r ti <br /> Contractor Ad License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REP-LACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> I } DISPOSAL FLO.� PROP. LINE <br /> f DISTANCE TO NEAREST: SEPTIC TANK 'aSEWER LINES <br />( LJ1 FOUNDATION Ib� AGRICULTURE WELL -�� OTHER WELL �- PITS/SUMPS S <br /> E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECT - YION <br /> ❑ industrial ❑ Open Bottom ❑ Manta Dia,of�Well Excavation Dia. of Well Casing <br /> yomestic/Private ave/ Pack ❑ Tracy � T-y�e-of Casing Specifications «J <br /> M Public they ❑ Delta Depth of Grout Seal Type of,,Grout _ <br /> 4 <br /> 14 Irrigation .-AIJprox. Depth--W-1-1-Eastern-�--- Surface-Seal-Installed-by.1e -MIA <br /> l t - 1, <br /> Repair Work Done; ❑ Type of1�Pump H.P. �� i State Work Done <br /> ii <br /> Well Destruction 11 �i.. ell Diameter ISealing Material {top 54'x,. - -- — <br /> Depth Filler Motorial IBelow50'1 ° I <br /> TYPE OF SEPTIC WORK'r- IEW INS,T, LhLATION­l REPAIRlADOITION'I I GTON-[�WNo-sel5tic system permitted if public sewer is <br /> avail;ble within 200 feet./, <br /> E Installation will s rve: Residence— Comm6rcial i Other <br /> I C M. x"' <br /> Number of livingiunits: Nurrlb�r of,bedraoms <br /> Character of soil'to a depth of 3 feet: 1 "�- �' Water table depth I ( <br /> �T { r I ` ,4j ' N <br /> SEPTIC TANK ❑ Type'/Mfg . 4 I t e Ca.paci No. Compartments i <br /> r PKG. TREATMENT PLT. ❑ { 1 ' Mithod of Disposal <br /> Distance to hearers: Wel oun ation _<rog rt Line � <br /> •Nr �� (� <br /> LEACHING LINE ❑ No. l L ngtrh of�li es tal length/site:��t r' <br /> FILTER BED ❑ Distance nearest fl * oundation "�--Prof�eity-Lin 1 <br /> I SEEPAGE PITS I i I Depth l Size t � Number l <br /> fiN y <br /> SUMPS Ll Distance to near , Well 1! Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this applicationAhIlowing: <br /> 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 HeaiMrictt <br /> urej <br /> i Home owner or licdnsed agent's sigbatcertifies t "I certify that in the performance of the work for which this p=ermit is issued, 1 shall not <br /> employ any person an such manner as to become subject to woi`kman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followirig: "I certify that'lin the performance of the work for Which this permit is issued, I shall employ persons subinc i to workman's compensa- <br /> tion laws of California." <br /> The applican ust i�ed i s plete hon r veawing ide. <br /> 1 i <br /> ( Signed X itle: �--� -- Date: ' <br /> FO DEPARTMENT USE ONLY i <br /> t Application Accepted by bate Area <br /> I <br /> Pit or Grout Inspection by ��� Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 § ❑ Lodi 369-3621 ❑ Ma teca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: EnvLr mental Health Pe it/Services 1601 E. Hezelta Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1,0V �jM7 A04, g <br /> kFEEO <br /> 1 AMOUNT DUE AMOU�NnT REMITTEQ CASH RECEIVED BY DATE rGFERMIT'NO. <br /> ♦.EH13-24iPEV.iix51 / 5r YS. � V -Cr/ /*-- lit) <br /> EH 14-26 �1 <br /> f. <br /> 4 <br />