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i <br /> r i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> j (Complete in Triplicate) �� �� <br /> to <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'Mcribed. This af� <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatiorts�fjt�.Sh' 4pgquin <br /> Local Health District. p '. �Nv1RRM�1150%0��`' <br /> Job Address � �1�L /�e!rV � i E�f eCity J Lat Size ! PM <br /> i 3�iC�L <br /> Owner's Name Aet79,t= E S&T2F_ Address 5Z-3� �����J��� Phone <br /> 6e&-la <br /> Contractor &AAtI6 Address License No. Phone <br /> TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .-"PUfVMNSTIVLr TIONS Ae-Z- SYSTEM REPAIR-fl THER--©- - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j FOUNDATIpN\N& -r c�AGFIICUL�TU�RErWELL OTHER WELL PITS/SUMPS _ <br /> -.... ... ..� Tom. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> :MomO lndust'rial l Open Bottom ❑ Manteca bia.'of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Publjci. f7 Other ❑ Delta Depth c4 Grout Seal T_ Type of Grout _ <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. ; State Work Done .Pim C��O <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 1 :Vega &zl <br /> j Depth Filler Material IBelow 501 1 <br /> TYPE OR:SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRtJf TION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Charactef of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity—L— No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> fDistance to nearest: Well Foundation— Property Line <br /> LEACHING LINE ❑ No. & Length of lines —L Total length/$size <br /> FILTER BED Cl Distance to nearest: Well j r..;� iyjo o datfEnr*' /Property Line <br /> _F ! <br /> SEEPAGE PITS f I Depth _-` izg �"' "" i Number <br /> SUMPS 'I 0 Distance to nearest: Well - FaVndatron 1 Property Line <br /> DISPOS4=PON[1S--4­0 <br /> 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 andli regulations of the San Joaquin Local Health Diltrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance thework 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: "I certify that in the performance of the work for which this permit is�issued fsha11 employ persons subject to workman's compensa- <br /> tion lawdof California." t <br /> The applicant s f i <br /> all re 'r nspections. Complete drawing on reverse side. ! <br /> !� <br /> Signed X i _ �iz� Title: , 2� !J _3 - <br /> Date: <br /> J. FOR DEP TMENT USE ONLY UI <br /> Application Accepted by y ) Date q k 7" Area <br /> Pit or Grolut Inspection by Date IAl 'Ft al Inspei tion by ! Date <br /> i <br /> Additional Comments: j <br /> ❑ 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 /> i <br /> IFEE INFO AMOUNT DUE AMOUNT.REMITTED CK 4 CASH RECEIVED BY GATE PERMIT N0. <br /> r.EH 13-24 IREV.t i,H 51 <br /> EH t4+28 ' <br />