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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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/ um and the Rules and Regulations of the San J <br /> Local Health District., p p e9 Joaquin <br /> Job Address ` G - .S s s r]/�� ����/ <br /> e� City Lot Size PM <br /> t Owner's Name ress _ <br /> r <br /> Contractor Address Phone <br /> License No. <br /> TYPE OF WELL/PUMP: Phone r <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANC EPTIC TANK SEWER LINES DISPOSAL FLD. PR <br /> OP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well x va' n <br /> Dia. of Well Casing <br /> ❑ Domestic/Private Q Gravel Pack —E7Trac`yam'""""Type df`Cerin-11,00"""" <br /> Specifications <br /> ❑ Public <br /> ❑ Other ❑ pelta Depth of Grout Seal <br /> ❑ Irrigation q T Y ut <br /> � <br /> pprox. Depth ❑ Eastern Surface Seal Installed by E <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter i 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 �q <br /> vailable within 200 feet.) V' <br /> Installation will serve: Residence_6)Comercial_ Other <br /> 4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ElType/Mfg `I ; Water table depth <br /> Capacity Nl. Compartments n <br /> PKG. TREATMENT PLT. ❑ ` <br /> e I— I It Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines i [ <br /> 4 l;, Total length/size <br /> FILTER SED O Distance to.nearest: Well Foundation t <br /> r. t f Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth <br /> -Size t NAber <br /> SUMPS ❑ Distance to nearest: Well _�' � Foundation'?� Property Line <br /> DISPOSAL PONDS ❑ +•j E 1 <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. I _„� I <br /> Home owner or licensed agent's signature certifies the following: '�l 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 em jo <br /> laws of California." • r.. P Y Persons subject to workman's compensa- <br /> tion <br /> The applicant must call for all uired ins in C lets drawing on reverse side. I <br /> Y Signed���., ,� .---- G� � Title: �.... ..�.. -.-..�.� <br /> Date: <br /> t <br /> FOR DEPARTMENTSE ONLY i <br /> Application Accepted by <br /> — Date Area 3 <br /> Pit or Grout Inspectign by Date Final Inspection by ��"'j��� <br /> Date�7 <br /> Additional Commen ce 10 X�pCd*W <br /> ❑ Stk 466-6781 ❑ Lodi 369-36.21 F 1 ❑ Manteca 823-7104 ❑ Tracy 839-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT''NO. <br /> + EH 13-24 f REV.!/a 5) r 3 <br /> EH 1428 <br /> "'W <br />