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7 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRI fl <br /> 1601 E._ HAZEL T ON AVE., STOCKTON, CA MAR 1987 <br /> ff Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 1=MENTAL HEALTf► <br /> (Complete in Triplicate) I L.111 IT/SERVICES, <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 /> Job Address O di. ity Lot Size PM <br /> Owner's Name Address 11131 Phone <br /> Contractor 4&--f M. %ALS..Address?© t�p X 1 �? License No./J2374:�) Phone 4 f <br /> TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Tvne of Grout <br /> ❑ Irrigation --Approx. Dept ❑t Eastern Surf ce Seal Installed b <br /> Repair Work Done (Type of Pump w b H.P. State Work Done It A"4 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 regul he San Joaquin Local Health District. <br /> Home owner r licensed ent's signature certifies! 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 ner as c e j t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t following:"I c that' t or an a of the rk for which this permit i iss ed,I shall employ persons subject to workman's compensa- <br /> tion laws f California." <br /> The appli ant must c all req i ed mp to drawing on rev Sid <br /> Signed Title: __ Date: <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by ��. Date /"�2 Area <br /> Pit or Grout Inspection Date Final Inspection by 0Date 7 S <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-636.5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> + EH 1 -241REV. C (=,in I Q D-,, <br /> EH 144 �.3` <br /> -26 <br />