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- I <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 TYEAR FROM DATE ISSUED <br /> 1 (Complete in Triplicate) <br /> { <br /> Application is he+eby 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 /> Locak'Health District. r ' 4 v"t� 8 <br /> �� @ Cit Lot Size PM <br /> Job Address 9 / Y <br /> ` Phone ti <br /> Owner's [Name Address <br /> Address <br /> r Contractor 4- .-�, Y[! /_C Address V C), License No�i�'�i%���Phone <br /> N9 d2- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7.. Dia. of Well Casing <br /> EJDomestic/Private '.iliGravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public n Other F] Delta Depth of Grout Seal Type of Grout _ <br /> I I Irr.igation-.—__"-,.,.._,_•-_._.Approx. Depth .."..I-I.Eastern___. .Surface.Seal Installed by_ - <br /> Repair Work Done ❑ Type of.Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Mat&W—Itop-501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION)< ,REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> . -... nce .. L� - available within 200 feet.) <br /> Installation will serve: Residence- Commer,l Iaic_ Other tL4 <br /> Number of'living_units: Number,of bediroomt- `�r /� G' <br />+ Character of soil to a depth of 3 feet: A O b e Water table depth <br /> SEPTIC TANK © Type/Mfg Pr.�.� Capacity Ee°U No. Compartments <br /> PKG. TREATMENT PLT. ❑ TT �:� Method of fDisposal <br /> Distance to nearest: Well FoundationProperty Line <br /> LEACHING LINE ❑ No. & Length of li s Total length/size ,"o <br /> FILtfER BEDi Distance to nearest: Well FoundationOF z Property Line <br /> SEEPAGE PITS i I Depth•' Size Number L <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> r <br /> DISPOSAL PONDS C7 <br /> 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 /> ruleg and regulations of the San Joaquin Local Health District. _ <br /> Hosie 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 tobecome 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 thV uuork for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Maws of California."i <br /> Y <br /> The'applicant must call for I requir inspections. Complete drawing on reverse-sidb. h' q+ <br /> Signed X Title:�rti %�_e r Date: t t <br /> R DEPARTMENTiJSE ONLY <br /> fir; f= z �ea ! <br /> Application Accepted by K- T ="Dale Ar <br /> Pit or Grout Inspection by Date Final-Inspection-by -bate <br /> 1 ; <br /> Additional Comments: I �! <br /> ❑ Stk 466-6781 L1 Lodi 369-3621 ❑ Manteca 823-7104 d Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.IH,azelton Aver, P.O. Box 2009,-Stk., CA 95201 <br /> SEE • • AMOUNT-DUE_ —AMOUNT REMITTED'— CK .T--.RECEIVED-BY-.�-—DATE--- —PERMIT`-NO-" <br /> R r INFO CASHH _ <br /> +.EH13-241REV.tie5f -- -_ - /wt <br /> EH 14-2a <br />