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- II <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA NI) <br /> Telephone (209) 466-6781 <br /> IE 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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /) Ih 1 <br /> Job Address le a f r O S+- City Lot Size PM <br /> 7608 S. ^w �f/� <br /> / Owner's Name I' , Address Iln ���r , � i Phone /t�) <br /> i / Du. Ua,. ooS _ <br /> I Contractor �p IC I Address 0?Q ©�✓G�d�4 �f License No. Phone_ f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM PAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> i ❑ Industrial ❑ Oprn Bottom ❑ Mante Dia. of Well Excav Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of <br /> no <br /> Specifications <br /> 1-1 Public Fl.Other 17 elta pth of Grout Seal Type of Grout <br /> I I Irrigation __Approx. Dapth 1 Easter Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State.Work Done <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth I Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> til } available within 200 feet.) <br /> Installation will serve: Residence! Commercial_ Other <br /> I 1 <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 C aci Dh <br /> mpartments <br /> PKG. TREATMENT PLT. ❑ '� Eof Disposal <br /> Distance;to nearest: Well Permit M-4da��tf [Mer y Line <br /> it I Work being U WI out <br /> LEACHING LINE ❑ No. & 4ength of lines �_ ��}}���� ��•''iit'', til� p�( <br /> FILTER BED ❑ Distancelto nearest: Well RiudktatlHpaittt t711T1 Line <br /> SEEPAGE PITS l I Depth Size !Number <br /> SUMPS ❑ Distancbito nearest: Well. Foundation Property Line <br /> DISPOSAL PONDS ❑ r I <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 <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 j <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 employ persons subject to workman's compensa- i <br /> tion laws of California." I ! <br /> The applicant must IE for all requi inspection Complete drawing on reverse side. <br /> . Signed X Title: �GU�u�L� Date: A9 �d <br /> OR PARTMENT USE ONLY <br /> Application Accepted by Date j �lJ Area <br /> Pit or Grout Inspection-by Date Final Inspection by Date <br /> b <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi i,369-3621 ❑ Manteca 823-7104 0 Tracy 835 6385 } <br /> If 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 *1CK RECEIVED BY DATE {� PfEERMn"NL0f. <br /> +•EH 13-24 IftEV.1/H 51 <br /> EH 14-29 <br /> �j <br />