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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (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 <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. <br /> t / i <br /> 00 <br /> Job Address � �� City � eot Size � � PM <br /> Owner's Namel Cil J6/Ts _T-pttAddress s r[ Phone 25 <br /> �. y. Contractor. PpZ, G"c1,C-_ rr ddress teo License-No. VS c have <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEEL REPLACEMENT ❑ DESTRUCTION O ; <br /> .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> L <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> s <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth _Filler Material (Below.5V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l< REPAIR/ADDITION I DESTRUCTION l I (No septic system permitted if public sewer is <br /> '-a'vaiiable-within 200 feet.I <br /> w Installation will serve: Re idence 0—<-f Commercial Other .' ' I' <br /> Number of living units: Number of bed corns + i <br /> Character of soil to a depth of 3 feet: LD�ri w _ — Water tattle depth , <br /> SEPTIC TANK Type/Mfg 8P/r r hf L Capacity 16® o No. Compartments <br /> PKG. TREATMENT PLT. ❑ el ' ';- Method of Disposal I <br /> Distance to nearest: Well 490 Foundation { Property Line /00 <br /> LEACHING LINE Ai�­No. 8r Length of lines Total length/size '2—2 <br /> FILTER BED ❑ Distance to nearest: Well Bd' Foundation z-S ( _Property Line--e"00 1 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 /> 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 airing 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 California." <br /> The applicant must call f r all re ired ins ctions.. C mplate drawing on reverse side. <br /> Signed X Title: Date: 611'a 2 <br /> NT USE ONLY <br /> FOR DEPART f� <br /> Application Accepted by Date Z,/— Area <br /> Pit or Grout Inspection by Date .Final Inspection by Date <br /> r <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601,E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO �]C SH <br /> + EH 3-24 EH 74.yalREV.riNSr l tires L1� ,p. �� 1191 9s <br /> � i <br />