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+may �y y� �r y} <br /> ' rA l MG ", <br /> APPLICATION FOR PERMIT RECEIVED <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA AU - 1990 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIRONMENTALRE-AUR <br /> (Complete in Triplicate) pEp, TISERVICEwS <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 Rutes,and-Regulatibns of the San Joaquin <br /> Local Health District, <br /> F <br /> Job Address --977 1 Cit Lot Size PM <br /> Owner's Name Address y� Phone !239-23'357Z <br /> Contractor Address)17� Aicense No. Phone 3 <br /> TYPE OF WELL/PUMP: NEW 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 /> ❑Y Industrial ❑ Open Bottom EJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — <br /> i`1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout n <br /> 11 Irrigation --Approx. Depth { I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') lir/ - —� ` 1 <br /> Depth Filler Material (Below 501 —_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (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 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wel! 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 hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issubd,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust all all required inspections. Complete drawing on re se Si e. <br /> Signed X� Title: Date: 1-L' <br /> F R.DEP RTMENT USE ONLY r <br /> Application Accepted by Date A + <br /> Pit or Grout Inspection by Data Final Inspection b Dat a <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 0 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT_NO. <br /> ♦ SH 13-24 1REV.i/115) <br /> EH 14.29 0 1 ( -L O 111 0~ o <br />