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" V/.1, w ti ✓ 1 � �"' ,�'. �. - <br /> iAPPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCANEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11YEAR FROM 'DATE ISSUED" " oil" <br /> ter, _ <br /> (Complete`in Triplicate}'h", —- -. + .r <br /> Gia„ <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 Ryles and Regulations of.the San Joaquin <br /> Local Health Drstn t?"'... �` �e•�4 � , <br /> Job Add /�' �Y"' I ', :. r <br /> { City of Size PM <br /> Owner's Name CIi-IAA-16A ,� Aill:oR i�Address C14 A• 4 Phone " �' <br /> Co raof r Address-,-,P/� OX L�/7� License No. Phone <br /> *� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP IN57ALLATIONQ�FiAc�MSM REPAIR E3OTHER L1DISTANCE TO NEAREST: SEPTIC TANK AA 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 /> ❑ industrial ❑ Open Bottom`a ❑ 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 /> ❑ Irrigations ; --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump FI:P. "" StatWor Done <br /> Well Destruction) ❑" WellDiameter Sealing Material (top 501 4? 15iJ� iP>�r�.t x <br /> Depth ' Filler Material [Below 501 <br /> �i <br /> TYPE OF SEPTIC I WORK:.-NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> a available within 200 feet.) ° <br /> Installation will serve:' Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms OD <br /> f9 <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I 1 <br /> PKG. TREATMENT PLT. LJ .+ Method of Disposal <br /> Distance to nearest: Well Foundations Property Line i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER SED / ❑ Distance to nearest: Well E .Foundation, Property Line # <br /> r1 i <br /> SEEPAGE PITS ❑ Depth , Size Number <br /> i <br /> SUMPS !<r; ElDistance to nearest: Well Foundation ^. Property Line i <br /> DISPOSAL�PONDS ❑ i ----- ---. QA... '' <br /> hereby certify that I have prepared this application and that the,`work will be done in acedrdance with San Joaquin county ordinances, state laws;-and l <br /> rules and regulations of the San Joaquin Local Health District. - <br /> 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 whichthis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." y <br /> The applicant st call r II quired inspections. Complete drawing on r verse side. <br /> Signed Title: d i K l4 d T Date: MI <br /> R D ARTMENT USE ONLY ` <br /> Application Accepted by DateZ�7ee,�_ A r <br /> Area <br /> Pit"or Grout Inspection by Dat Final Inspection by Date 7 <br /> Additional Comments: `- <br /> ❑ Stk.,466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Ll Tracy 835-6385 i <br /> Applicant- Return all copies for Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT"NO.' <br /> + EH 13-24(REV.1/s 51 „y <br /> EH 14-25 S.V C? 1�` T S --7�ls <br /> _� <br />