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a41 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E'.,.HAZELTON\AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t 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 />! Local Health District. r i �( `Zd �/ <br /> ot�r�s ,�:,�=� . <br /> Job Address IAJ W, 0 r' a City r Lot Size PM <br /> Of <br /> Owner's Name, Address ``tf/ PhoneAI <br /> ���7� C�Q 'fir C�z 6 <br /> .. 'Contractor Address nse No. fione_ <br /> -xTYPE OF WELL/PUMP: NEW WELL IV WELL REPLACEMENT DESTRUCTION ❑ <br /> N _ PUMP INSTALLATION ❑­ , SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. r PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOKSCI (( ` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casi <br /> ❑ Domestic/Private 0011110alell Pack ❑ Tracy Type of Casing Specificationst'� <br /> t'1 Pu tic Ll Ojher ❑ Delta Depth of Grout Seal T f Grout _- <br /> 0 <br /> rngation .Approx. Depth �.-I II-Eastern ,, Surface Seal tristallad by S <br /> Repair Work Done L� Type of Pump D H.P. -- tate Work Done- <br /> + C, <br /> Well Destruction ❑ Well Diameter Sealing Material (top.50'1 r r <br /> Depth Filler Material (Below 50') 130 Com" y <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l .I Wo septic system permitted if public sewer is <br /> 1 ' available within 200 feet.) <br /> _installation will serve: Residence_ Commercial Other A a <br /> Number of living units: Number of bedrooms_ y 1r r j <br /> Character of soil to a depth of 3 feet: Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method,of Disposal ' <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> k`I <br /> SEEPAGE PITS I Depth Size Number ' <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> iI hereby certify that I have prepared this application and that the work will be done-in accordance with San Joaquin county ordinances, state laws, anc <br /> f rules and regulations of the San Joaquin Local Health District. <br /> Home owner or Gc age ignature certifies the following: "I certify that in the performance of the work for which this parmit.is issued, I shall n o <br /> employ any per n in such manna s to become subject tow an's compensation laws of California." Contractor's hiring or sub-contracting signatun i( <br /> + certifies the fo wing: "I certify tha " the rfor a oft rk for which this mit is issued, I shall employ persons subject to workman's compens' <br /> tion laws of lifornia." I I, <br /> The applican must ca f uired s` late dra ing on rever d J l <br /> Signed <br /> IFDEPARTMENT USE ONLY !! Q,r�, `-�,• ' <br /> zza7 <br /> Application Accepted by Date ^ I ��-I V- Area i <br /> Pit or Grout Inspection by Date Final Inspection by% � Date <br /> to—l4''4 <br /> Additional Comments:'yr�a I! `l 0 V el- <br /> L3 <br /> � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63851 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> k �] <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, <br /> INFO CASH f <br /> +.EH 113-24{flEV.t/n51 c�� �l� � A) ", <br /> � <br /> EH 1429 <br />