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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> d <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. w �` <br /> Job Address i. VQ /� _'�+sCity^ L� Lot Size PM <br /> Owner's Name Address 6 Al Phone <br /> �� I-1�� f _ Address---- 33 111 IQ�� � — ` ?-�7 <br /> Contractor, „ � c�' p�C9� License No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LIQ _OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC•TANK-- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ 'AGRICULTURE­WE'LL- OTHER WELL PITS/SUMPS <br /> INTENDED-USES.-...TYPE_OF W..ELL,PROBLEM.AREA.,.,.,CONSTRUCTION_.SPECIFICATIONS. —,.,.___._ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F U11T0`mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> y ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___2Approx: Depth t❑ Eastern Surface Seal Installed by <br /> Repair Work Done f lType of Pum�pYtit-Itis H.P. l State Work Done L� <br /> Well Destruction.4i. Ll Well Dlemeter; ti-_ �-� Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTAC1ATCDN ❑ REPAIR/ADDITION ❑ DESTRUCTION LJ-,(No septic system permitted if public sewer is �J <br /> $ kavailable within 200 feet.) r ' <br /> Installation will serve: Residence_ Commercial Other `f <br /> Number of living units: Number of bedrooms <br /> 4- a <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg '' Capacity : No, Compartments t <br /> a. <br /> PKG. TREATMENT PLT. 170 D • `' Method of Disposal <br /> Distance'ti3 nearest:.--- Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengtWsize <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line ( _ <br /> SEEPAGE-PITS^,^��"^'❑"-Depth Size Number --- -- - --^f Co <br /> sumps ; € ❑ D'istance�to`nearest401 WelllFoundation- :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. y <br /> o 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 which this permit is issued, I shall employ persons subject to workman's'compensa- <br /> tion laws of California." <br /> The applica s call for all requir d ns c ns. Completerawing on r er a side. 4Je d <br /> Signed A itle: _ Date: <br /> FFOR DEPARTMENT USE ONLY <br /> Application Accepted by', S Date � AreaAlfA <br /> . Pit or Grout Inspection by Date Final Inspection by Date <br /> l +rr•w <br /> Additional Comments: ` ~ i£ <br /> ❑ Stk 466-fi781 ❑ Lodi 369-3621-* i. `�-❑ Manteca 823-7104 ❑ Tracy 835-6385 t ` { <br /> Applicant'-Return all copies to:Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.0 x Box 2009, Stk., CA 95201 <br /> NA <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BYE, DATE PERMIT"NO. <br /> f + EH 13-24(REV.I/a 5) ' <br /> EH 14-26 <br /> f <br />