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1 ".• S <br /> " APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 17 <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ` ��„ <br /> Telephone 12091 466-6781 <br /> I/ <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�d,yyscribedd.TT��San ataon s <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and thf-MMROHM ry <br /> Local Health District. ` PERMIT/SERVICES <br /> / /Lw Ci Size PM — <br /> Job Address - - �_r <br /> nr <br /> Address Phone <br /> 0 Name h I7 1 <br /> Contra _ <br /> _ dress__ 1__ x `� Licennsse Ho.r�'s1�23?3 Phone <br /> TYPE OF WELL/PUMP: NEW VIFLL ❑ WELL REPLACEMENT ❑ DESTRUCTION r:.l <br /> PUMP INSTALLATION ,tom SYSTEM REPAIR F1 OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES ._ DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _._BOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L] Industrial LI Open Bottom LJManteca Dia. of Well Excavation _ Dia. of Well Casing <br /> � S ecifications � <br /> �mestic/Private t_l Gravel Pack L Tracy Type of Casing__ P T <br /> II Public l i Other 17 Delta Depth of Grout Seal Type of Grout -- <br /> 1 Irrigation __ Approx. De I I astern Surface Seal Installed by I's Repair Work Done LeType of Pump � H P State Work Rorie`�_.Well Destruction Ci Well Diameter Sealing Material (top 50'IDepth Filler Material IBelow 50'] �_TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l i DESTRUCTION I I INo septic syste pe milteditpubli sewer <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ —_. Water table depth <br /> wSEPTIC TANK LI Type/Mfg Capacity._ — No. Compartments <br /> PKG. TREATMENT PLT. 1_1 Method of Disposal <br /> Distance to nearest: Well Foundation__ Property Line <br /> LEACHING LINE LI No. & Length of lines Total length/size <br /> FILTER BED I 1 Distance to nearest: Well_ Foundation _ Property Line <br /> SEEPAGE PITS i I Depth _ Size Number <br /> SUMPS L! Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS E <br /> I hereby certif have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules an eguI tions o e San Joaquin Local Health District. <br /> Ham caner or licensed a nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> em oy any person in such anner as to b come subj workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> c if res <br /> the folio g: "'1 ce ify that in rf th <br /> a e work for which this permit is issued, l shall employ persons subject to workman's compensa <br /> f n laws of Califor ia." j <br /> he app/ ant m I or all req ample drawing o r e e. �. <br /> Si d X <br /> Title: v Dater <br /> OR DEE MENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date t E <br /> Additional Comments: <br /> L 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 /> FEE AMOUNT DUE AMOUNT REMITTED--CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> V <br /> . EH 13-241REV.i!n�; AC^ i'�.�.� �o 4. ��L—. <br /> EH 14 26 <br />