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T a.� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE; TON AVE., STOCKTON, CA ° IN <br /> Telephone (209) 466-6781 No « R�l k... � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i# (Complete in Triplicate) iL"- (. 6Z� <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. I+ <br /> Job Address _f V& City �S+ Lot Size �l M ! <br /> Owner's Name Address Phone <br /> f # <br /> Contractor Address 360 l�l_f« � �d�License No. J��c�. Phone T 4 <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 AREA­CONSTRUCTION SPECIFICATfONS' " " " " "" " ^—~•�� <br /> ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications <br /> I l Public C1 Other t] Delta Depth of Grout Seal w Type of Grout <br /> I I Irrigation _Approx. Depth- 4-1 Eastern----Surf ace-SiDdl installed 6y <br /> Repair Work Done ❑' Type of Pump ) H.P. State Work Done g� <br /> Wel! Destruction ❑ Well Diameter„I Sealing Material (top 50') <br /> Depth I �' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION I.I `DESTRUCTION [ septic system permitted if public sewer is <br /> 1 ( available within 200 feet.) <br /> Installation will serve: fie 'd ice_' mmercial_ Other <br /> Number of living units: Numbsr,of bedrooms T f <br /> g <br /> Character of soil to a depth of 3 feet .� <br /> a Water table depth <br /> SEPTIC TANK L7 Type/Mfg . Capacity :No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t <br /> Distance to'nearest: Well "Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth - - Size Number <br /> SUMPS ; 1 D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS t❑ <br /> 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, 1 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 /> ce the followin • rtify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws lif a." , <br /> The applican mu !I f l e drawing on r arse side. <br /> Signe Titla: <br /> - � Date: <br /> I <br /> F- ARTMENT USE ONLY q <br /> r <br /> Application Accepted by Date �� S"� Area <br /> Pit or Grout Inspection by ~T Date <br /> Final Inspection b Date 2—1G—"rte <br /> Additional Comments: t <br /> ❑ Stk 466-6781 : ❑ 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 /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERM17 Np, <br /> INFO CASH <br /> +.EH 13-21(REV.t/x 5) 3S� ,^1 <br /> EH 11-28 -(J (J � <br />