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B <br /> 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 /> (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. /� '�j <br /> Job Address <br /> I�`[1 50 City of Size ?C v PM <br /> t <br /> Owner's Namef fi 'SC✓r 1 2 10JAn't ri ` Address Js( Sv — Phone, <br /> _ _ �� ._ <br /> jos <br /> Contractor's Name �,�r�� ` - �� License No. AS�^ Phone54 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ w v,WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR; 1:1w L OTHER <br /> DISTANCE"TO NEAREST: SEPTIC TANK" SEWER-LINES DISPOSAL"FCD. PROP.`LINE <br /> FOUNDATION AGRICULTURE,WELL OTHER-WELL PITS/SUMPS ; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA wCONSTRUCTION SPECIFICATIONS 4 <br /> c_.a,❑ Industrial _ ❑ Open Bottom _ ❑ Manteca , Dia:`of,Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Casing Specifications- - <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern .• Surface Seal Installed by -- G <br /> Repair Workbone ❑ .,Type of Pump H.P. y State Work Done ± <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 i1 <br /> Depth ' Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALL'ATIO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation vWl'serve: Residence_—Comme�ciah -Other— <br /> Number <br /> therNumber of living units:,—_Number­of-beproorr <br /> Character of soil to a depth of 3 feet: C t Water table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity �0 0 ® No. Compartments 2 I <br /> PKG. TREATMENT PLT. ❑ / Method of Dispgsal <br /> Distance to nearest: Well X% Foundation Property Line s. <br /> LEACHING LINE No. & Length of lines C 7 6 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well >�� Foundation > /a / Property Line l <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well> 1,50 Foundation > /0 � Property Line <br /> DISPOSAL PONDS t ❑ <br /> I hereby certify that;Lhave.prepared.this application.andrthat.the.work.will.be.done,in,accordance_with_San-Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican t call for all required inspoctions. C mplete drawing on rev <br /> � � <br /> Signed-X Title: Date: � <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by e-5'f�' - �- °• `` Date s ` -� C( Area <br /> Pit or Grout Inspection by Date q'ozs�� Final Inspection by Date2 <br /> Additional Comments: <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0. <br /> i INFO CASH <br /> + EH13-24 IREV.10/83) <br /> EH 14-26 <br />