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APPLICATION FOR PERMIT <br /> 2A " _ <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601-E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,- <br /> (Complete <br /> SSUED ,.(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. 1861 for well/pump and the Rules and Regulations of the San Joaquin <br /> l Local Health District-7i x <br /> OL A <br /> Job Address �. City Lot Size 91 ,21 PM <br /> yf/- X69 <br /> Owner's Name Address Phone <br /> rv� Z <br /> Contractor D Address �./ )C License No.wf3 Phone 2` <br /> TYPE OF WELL/PUMP: NEW WELL ❑J ` WELL:REPLACEMENT Ll ' DESTRUCTION ❑ <br /> r " P0MP`I AL'LATICN'❑"" L"SYSTEMrREPAIR' O R`❑" "� �� <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD PROP. LINE <br /> I FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL BLEM AREA ONSTRUCTION SPECIFICATIONS V <br /> ❑ Industrial b❑ Open Bottom ❑ M eca Dia. of Well Excavation pia. of Well Casing ` <br /> ❑ Do�rlestic/Private ❑ Gravel Pack ❑ Tra Type of Casing <br /> i . S'�cifications <br /> lei <br /> ❑ Public ❑ Other elta Depth of Grout Seal Type of�Grout {� <br /> r'�-❑ Irrigation _Approx. Depth ❑ Eastern Su a Seal Installed by <br /> RepairWork Done ❑ Type of Pump H.P. r State Work Done _ 9 <br /> Well Destruction Cl Well Diamet Sealing Material„(top 50') 7 <br /> Depth Filler Material (Below 50') <br /> .,TYPE OF SEPTIC WORK: NEW INSTALLA ION ❑ REPAIR/ADDITION D STRUCTION ❑ (No septic s em permitted if public sewer is <br /> I � ! � ! j avail a in 200 f e <br /> Installation will serve: Residence, Commercial_.Other ! <br /> ° Number of living units: Number of bedrooms`- ��' <br /> €€ Water table epth # <br /> �x ChaPacter of soil to a depth of 3 feet: <br /> + 'SEPTIC TANK ❑ Type/Mfg a Opacity No. Compartments <br /> �PKG. 6FATMENT PLT. ❑ 4l�'� I� - [ Method of Di oral y l <br /> w� Distance to nearest: Well 1 Foundation Property L'Ine - <br /> F LEACHING LINE ❑ No. & Length of fin ' ti' Total length/size <br /> FILTER BED ❑ Distance to neares . - r+ dation ' . ;Property Line, I•--�' I <br /> SEEPAGE PITS ❑ Depth Size. `� ' Number <br /> SUMA ❑ Distance to'nearest: Wel! found,ron Property Line <br /> DISPOSAL PONDS.__❑ - — __ . _ - _ ___•:_ �- _ -- - --�...._-� <br /> I hereby certify that I have prepared this application and that the''Work.will,be,dbne in.accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. f <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 hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for iefi-this permit is issued,'l shall employ persons subject to workman's compensa- <br /> tion laws of.California." ; <br /> The applicant u�st call III requir d inspections. Complete drawing on reverse side. <br /> Signed — Title: _ Date: <br /> r <br /> FOR DEPARTMENT USE ONLY +�. <br /> Application Accepted by Date 2--O Area <br /> Pit or Grout Inspection by Date Ainal Inspection by Date <br /> Additional Comments: <br /> , L C } <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 83546385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ti t <br /> FEE AMOUNT DUE AMOUNT REMITTED CLASH RECEIVED BY DATE PEIRMIT''NO. <br /> INFO �! r <br /> +rEH 13-24 <br /> (REV.ti i e 57 <br /> ?EH 14-28 l <br /> i <br />