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APPLICATION FOR PERMIT ; - ." <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> -�' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <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 Lf� <br /> made in cornpliance with San'Uoaquin 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., 7"4/J � <br /> Job Address I' Z City t Size PM <br /> Owner's Name _ dFess <br /> /� Phone <br /> Contractor4�a - dress License No. �Phone_ <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ VVELL REPLAPEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION ❑ SY_ REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS {t <br /> ❑ In ria--I ❑.Open Bottom Ll Manteca Dia. of Well Excavatio Dia. of Well Casing <br /> 3 omestic/Ohvate ❑ Gravel Pack 0 Tracy Type of Casing Specifications; �r <br /> r ❑ Other F1 Delta Depth of Grout Seal Type of (aut, <br /> f`1 public ,. P I - <br /> ' t dation ��!._Approx. Depth i I Eastern Surface Seal Installed by - <br /> 1 Repair Work Done ❑ 4pe of Pump H.P. State Work Done <br /> ' 0. <br /> r Well Destruction` ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Material IBalow 501 <br /> t — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted ifipublic sewer is <br /> ' available within 200 feet.) <br /> �- installation-wi[Lserve= Relr�;h+'dence—.�G rnmer-cial=-!Other <br /> 1 <br /> Number of living units: SIM Number of bedrooms <br /> ' 'Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK J © Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i^ <br /> DistanoNto nearest: Well FoundatibO Property Line <br /> LEACHING LINE LI No. & Length of lines l Total length/size <br /> } FILTER BED Q Distanceito nearest: Well Foundation Property Line N <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C7. . <br /> I hereby certify that I have p!epared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 /> i 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 Ito workman's compensa- <br /> tion laws of Califo�cal <br /> " <br /> The applicant �Str i ired -nspections. Complete drawing on.' arse 'de. t <br /> Signed X JJ <br /> Title: date: <br /> FOR DEPARTMENT USE ONLY <br /> gi <br /> Application Accepted by E' Date < -Area J 2 <br /> pi' .c <br /> Pit or t rot Inspection by Date ._. Final Inspection by ._ Date/_ <br /> Additional Comments: II� <br /> ID Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies!6: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 952011 z <br /> r i ! <br /> FEE <br /> INFO AMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 'kn d <br /> +.EH13241REV.i/H51 I�✓f (�/IS �7 �. 1 <br /> EH 1426 <br />