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3596 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 <br /> 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..TNs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and.the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> y,.. s ♦. '.:i_ } .. ,�J.•5- wok � <br /> q 1 <br /> Job Address / GvG?-od 5-M ` ' City . 'Lot Size PM <br /> Owner's Name .-vS a w _ Phone <br /> Address � .�..� <br /> Contractor Address 121 License No2? 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑d' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA I CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WA Excavation Dia. of Well Casing q <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ 3 of CasingV Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout_S al , E Type of Grout ,\ <br /> F1 Irrigation �gpprox. Denptth ❑ Eastern Surflce Seal I'nstalledrby <br /> Repair Work Done Q' Type of Pump c� H.P. t � State Work Done <br /> Well <br /> Well Destruction ❑ Well Diameters - Sealing Materihl (top 50') & <br /> Depth Filler Material {Below 501 - } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A1DDIT^ION11E, DESTRUCTION ❑riNb�septic system permitted if public sewer is <br /> 14 ��� 1aiiailable within 200 feet.) <br /> , 'T ' <br /> Installation will serve: ResidenceComOther - <br /> mercialk ,��� s <br /> Number of living units:- --- Number of-bedrooms=- ---� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 1 <br /> SEPTIC TANK C1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 3 <br /> Distance to nearest: Well Fdundation Property Line <br /> P rtY <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth r Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS j ❑ r }i <br /> hereby certify that I have prepared this application and that the work will tse done in accordance with San Joaquin county'ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. 41'4 <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 com ensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for whichWis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I / <br /> The applicant c II for all re ed inspecti ns. Complete drawing on rvers a sid <br /> ee. ! <br /> �]� f <br /> Signed J "` <br /> g /"�fitle: Date: / �L � <br /> 17 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by )) 671Date I d Area <br /> Pit or'Grout Inspection by b Date Final Inspection byA V Date <br /> Additional Comments: l <br /> ❑ Stk 466-6781Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 •� <br /> Applicant Return all opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE 7 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. s <br /> +EH 13-24{REV.1/651. <br /> EH W28 3 ♦ oo .� S� M_7—�'� <br />