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!r <br /> h <br /> ZA � l� n APPLICATION FOR PERMIT <br /> .X SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> (Completelin 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 <br /> made in compliance with San Joaquin County Ordinance Na. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. � ` } <br /> Job Address ��J ►y1e �1u7 4) City k)Lot Size PM <br /> Owner's Name1(%SALAddress O <br /> Phone <br /> Contractor <br /> `pr.knl p � ddress License Npp Q <br /> o.r �Q'd Phone <br /> TYPE OF WELL/PUMP: -.+ -NEW WELL-Ft — ­WELL-REPLACEMENT❑r. _r- aDESTBUCTION ❑ i <br /> PUMP iNSTALLION SYSTEM REPAIR ❑ � OTHERS❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK . SEWER LINES DISPOSAPROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _S7 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial. ❑ Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Well Casing <br /> e�omestic/Private LYUravel Pack ❑ Tracy Type of Casing„ Specifications f <br /> F1 Public 71 Other C1 Delta Depth of Grout Seal d.,- Type of Grolrt l� �f <br /> I I Irrigation --Approx. De th i I Eastern Surface Seal Installed by <br /> �'/ '; _ <br /> Repair Work Done �Type of Pump �0a�_ _ H,P. - 1 State Work Done <br /> Well Destruction ❑ Well of <br /> ;Sealing Material (top 50')` <br /> Depth. # I [F-iller_MaterialIBelow-50'y <br /> A <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONf-1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is <br /> I <br /> available within 200 feet.) I <br /> Installation will serve: Residence— Commercial_ Other to <br /> Number of living units: Number of bedrooms <br /> a Character of soil to a depth of 3 feet: t f <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity " ,No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation - � Property Line <br /> j <br /> LEACHING LINE i 1FI No. & Length of lines Total length/size p <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS ;I I Depth j Size <br /> Number <br /> SUMPS L1l,,Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and t at the work w_iil_be done in accordance with San Joaquin county ordinances, state laws, and <br /> ._ <br /> rules and regulations of the San Joaquin Local Health District. 1 <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 becorne.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 compensa- <br /> tion laws of"C`alifo`rni5-' <br /> The applican st call for all required ins I <br /> q pections. Complete dr wing verse side, <br /> Signed X Title:' <br /> - (/�' AF IV <br /> Date: <br /> ARTiNENT USE ONLY <br /> Application Accepted by ; <br /> _ Data Area _ <br /> Pit r G o Inspection b Date�i _ Final Inspection <br /> Date <br /> Additional Comments: 11 1) <br /> ❑ Stk 466-6781 ❑ Lodi 349-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 F <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. <br /> + EH13-24(REV.lirs5l f f rl o <br /> EH 14-28 {, Vv 6$ �� <br />