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1 ! <br /> • •- " - ' ,..,.. , .ter_ r <br /> APPLICATION FOR PERMIT <br /> SAN�JOAO.UIN LOCAL HEALTH DISTRICT , <br /> 16011 E?HAZEL TON AVE., STOCKTON, CA •l <br /> � i <br /> Telephone (209) 466=6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> SQA = - <br /> (Complete in Triplicate) F <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thrs application <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San JoagOin. , <br /> Local Health District. < : <br /> '. Q' I F v Carr <br /> Job Address /01 ��L� /fG r City ' Lot Size :7y Y f6 PM <br /> Owner's Name. � Address 32 `�Y �� -6 Phon� q � '• <br /> Contractor Address=--Z' ---License No.--'--' Phone <br /> TYPE;OF WELL•/PUMP,:\ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ YS <br /> REPAIR ❑ OTHER ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES D 5AL FLD. PROP. LINE '! <br /> FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL P1ROBLEM AREA CONSP5ION.SPECIFICATIONS \f� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Welly " a'tiori` ' Dia, of Well Casing <br /> , <br /> ❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of'Ch9ing $ , .- I Specifications <br /> ❑ Public ❑ Other � Delta epth�f Grout So 11 Type of Grout <br /> El Irrigation --Approx. Depth © Ea rn u a e 5eal�Installed by <br /> Repair Work Done ❑ Type of Pump H.P. a State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Mate al (top 501 i <br /> � r <br /> Depth illl6r atena l iaow l r I l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTAUCTION, (Nd septic system permitted if public sewer is <br /> ' 4 available within 200 feet.) <br /> Installation will serve: Residence.X_ Commercial_ Othtr r. i <br /> Number of living units: Number of bedrdoms< (,r <br /> Character of soil to a depth of 3 feet: ` l �: ! # t Water table depth + <br /> j SEPTIC TANK Type/Mfg ' r! r Capaci _"J ' No. Compartments " <br /> PKG. TREATMENT PLT. ❑ Method of Disposal } <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines .�)v INotal length/size `• I <br /> FILTER BED ❑ Distance to nearest: Well Foundation 'r% Prtperty Line <br /> E Fy <br /> fiY I <br /> SEEPAGE PITS LlDepth Size ,Number <br /> - <br /> SUMPS ❑ Distance to nearest: Well FoundationPr party Line <br /> FFlly <br /> DISPOSAL PONDS ❑ <br /> 1 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 and regulations of the San Joaquin Local Heath District.. - ` : r . <br /> Home owner or licensed agent's signature certifies tF a following I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ anrpetson 6-such-Mahfib- -aV'tb'li&om""�siil5i6cf£o workman s compensationlaws of California."Contractor s hiiing oi'sub-coritractirig signature <br /> certifies the following:"I certify that in the performance of the work fo�•which this pert_nit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Ca' r ' . %. . <br /> T lic m t cal for all r i se ct ns. Complete drawing on re rsesido. r ,;: r 1 <br /> Signed ._ -R Title:; ' +, Date: r <br /> FOR DEPARTMENT USE ONLY <br /> i Application Accepted by Date Area Q� J� <br /> Pit or Grout Inspection by Date Final Inspection by Dat "f0 U <br /> • Additional Comments; - <br /> F <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO,} <br /> + EH 73-24(REV.t/851 ', <br /> EH 1M28 ✓ r !✓v / 1� ' <br />