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' � r <br /> I APPLICATION FOR PERMIT <br /> c'v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> \��CjV 1601 E. HAZEL T ON AVE., STOCKTON, CA SCAMPOED . <br /> u Telephone f 2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - (Completeiin Triplicate) <br /> C Application is heieby 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. " <br /> �.+.7r- <br /> Job Address City a'-'Cot Size PM <br /> A <br /> Owner's Name r 4Ta Address P: <br /> Phone <br /> ContractorAddres �� �L-� License No.317�Phone 2 7 <br /> TYPE OF W LL,LPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP;INSTALLATION ❑ SYSTEM REPAIR ' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES" DISPOSAL FLD.' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ OPenIBottom EJ Manteca . Dia. of Well Excavation Dia. of Well Casing I A <br /> F ? Domestic/Private LJGravel Pack ❑ Tracy Type of Casing Specifications <br /> I <br /> 171 Public F] Other{ 11Deltaof Grout Delta Depth of Grout Seal T 1 <br /> ❑ Irrigation _�lpprox. Depth P Eastern Surface Seal Installed by <br /> Repair Work DoneType of Pump H.P. s, State Work Done C, EIL <br /> Well Destruction Cl Well NI arneterSealing Material (top 50') <br />{ Depth} " Filler Material (Below 501 <br />? TYPE OF SEPTIC WORK: NEIN,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) f <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Al.Number of bedrooms.-A." I , <br />( Character of soil to a depth of'314eet- <br /> v Wates table depth *� <br /> SEPTIC TANK ❑ Type/Mfg ? t Capacity-1 �' No- Compartments <br /> PKG. TREATMENT PLT. ❑ I;Y <br /> tr Method of Disposal <br /> -- s <br /> '.Distance to nearest: Well Foundation Property Line <br /> �` <br /> r �� <br /> LEACHING LINE ❑ No. &Length'of linesTotal length/size <br /> FILTER BED ❑, Distance to nearest: Well 'Foundation Property Line .r <br /> SEEPAGE PITS ❑ depth, _ ' Size -r _r _ Nu_m_ber _ <br /> SUMPS ❑., ,pstanc' nearest:- - Well Foundation Property Line <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 ordinances, state laws, and <br /> p rules and regulations of the SanSJoaquin Local Health District. <br /> I Home owner 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 co pensa- <br /> tion laws of California." <br /> 1 <br /> The applica call for all req ins ions. C plete drawing on reverse side. <br /> Signed X L% Title: SDate: OP <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspecti # Date Final Inspection by Date <br /> { <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 /> INFO AMOUNT DUE �RMITTEDCK RECEIVED BY <br /> G?1$H� ;" DATE PERMIT NO. <br /> ♦'EH 47241REV.7i8s1 (.0) <br /> �� , <br /> EH14-26 � `�1/\ <br />