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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Z 4 1601 E. HAZEL <br /> TON AVE., STOCKTON, CA <br /> Telephone(209)466-6781 <br /> PERMIT EXPIRES 1,Y <br /> EAR FROM DATE ISSUED <br /> (Complete in'Triplicate) - <br /> Application is hereby made to the San Joaquin Leal Health District for a permit to construct and/or install the work herein dewibed.This 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 /> Job Address,I/ / 1f N/. li[�4:-;.��,�fir7.-„�, � - <br /> City LotSiwe OXALd4X PM <br /> fj <br /> Owner's Name AddresaZfffA, - ;=- ,° <br /> Phone <br /> ., r 7�9 - <br /> Contract AddresSr, License,No fo?g& Phone -576r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WL REPLACEMENT ❑ "DESTRUCTION <br /> PUMP INSTALLATION ❑ SY EPAIR ❑ OTHER ,❑ ? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. - ". DISPOSAL FLD PROP, UNE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/DUMAS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Wel Excavation Dia..'of WeN'Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout- <br /> 0 <br /> Irrigation _i4 _ __ _ - <br /> pproz. Deptfi' ❑ Easfem Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Do i <br /> Well Destruction ❑ Well Diameter <br /> i <br /> Seating Material (top,-501 <br /> Filler Material 4-Below, } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION❑ (Noseptic system permitted if public sewer is <br /> , <br /> Installation will serve: R ' ava�awithin 200 feet.! <br /> ble ce Commercialz�ther <br /> Number of living units: Number of rmo J <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Up" Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT.❑ / Method of D�apcisaI <br /> Distance to nearest: WeII, � Foundation / property Lina <br /> LEACHING LINE �No: &Length of lines Total length/size ' �a <br /> FILTERBED ❑ Distance to neerest- Won Foundation /j� Property Line <br /> SEEPAGE PITS; ❑ Depth <br /> SUMPS ❑ Distance to nearest: Well - "--Foundation Property Lida <br /> f <br /> DISPOSAL PONDS ❑ _.. <br /> I hereby certify that I have prepared this application and that the work will be done in,accordance with San Joaquin county bAllhanc;es, to laws, and Y <br /> rules and regulations of the San Joaquin Local Health:District.. <br /> Home owner or licensed agent's signature certifies the following:"1 certify g rtify that is the performance of the Vvo for which this permit is , I shall not <br /> employ any person m such manner as to become subject to workman's compensatkmn laws of Caiiforraa. tr is Kiri or sub-contract! <br /> certifies the following:"I certify that in the performance of the work for which this Pemi sued,I shall signature <br /> Son Taws of Califom�a. empkmy persons subject to workman's mper►sa- <br /> P <br /> ,^ T <br /> The applicant caN `► II 1 quired inspections: Complete drawing on reverrse <br /> lo <br /> Y <br /> Signed Trtle: �Data; <br /> ,FOR DECARTMENT E ONLY <br /> Application Accepted b <br /> ccep y <br /> Date ..�`If Arm <br /> -_ <br /> Pit or Grout Inspection by Date Final Inspection by p <br /> aft <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 389-3521 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,S*,, CA`952I* <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK , <br /> RECEIVER BY DATE PERi�4Mf1' <br /> 77 <br /> GAS <br /> +EH 13.27(REV. /8 5) = <br /> EH W26 L7 rry <br /> t <br />