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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ro <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> R Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f <br /> .y . <br /> ,k <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 incompliance with:SanJoaquin 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 /> . y Cit <br /> 'S` T� Lot Size PM <br /> Job Address <br /> /l��. I // yvmfoo - Address ���� S � Phone <br /> Owner's Name1 IrEJ� 11 <br /> Contractor � � <br /> Address License No.��)-Phone <br /> l TYPE OF WELL/PUMP: !tZZNEW <br /> WE <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA VON / SYSTEM REP R ❑ OTHVR ❑ E <br /> IDISPOSAL FLO.JCr/-J—PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> `"- INTENDED USE "'TYPE OF;WELL'- "'PROBLEM AREA CONSTRUCTION SPECIFICAT <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavati <br /> Dia. of Well Casing (�J <br /> Specifications <br /> r <br /> l ❑ Domestic/Private (�ravel Pack / ❑ Tracy Type of Casing I p <br /> ❑ Public ❑ O r /f/d ,# Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation �A ox. Dept ❑ Eastern Surface Seal Installed by!��tr <br /> Repair Work Done_ Ll Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK:- NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK EJ Type/Mfg Capacity No. Compartments <br /> i Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line y� <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size p <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> t <br /> SEEPAGE PITS ❑ Depth{ Size Number <br /> b # <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application"and that the work will tie done ih accoFdarice wiih`Sari 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 shah not <br /> employ any person in such manner as to become subject to workman's compehsation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that 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 r9dffZ11 for requir i pections. Complete drawing on rse side. <br /> Title: Date: <br /> Signed X f <br /> FOR EPART USE ONLY <br /> 4 1 <br /> 4 Date Area <br /> Application Accepted by g <br /> -i IDate Final inspection by Date <br /> Pit or Grout Inspection by / <br /> Additional Comments: _. <br /> El Stk 466-6781 -" 0 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 /> P�t 3 <br /> FEE MOUNT DUE EAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> EH 13-24IREV.1/9 5) - -7 0,60 � � <br /> EK 1428 <br />