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, J <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781' , <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED" <br /> i' (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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address /5O' 1�+ny!! {Q f/� 2��G� <br /> =�+�, City AG Lot Size M /�" PM <br /> Y <br /> Owner's Name 6g�,Tb,5 I:A�1id,* Address = <br /> # _ { Phone <br /> E I Contractor 4 I-eil- Address License No. 2 <br /> ��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <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 t <br /> f. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Df Well Excavation Dia. df Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications . <br /> I ❑ Public ❑ Other ❑ Delta Depth of.Grout Seal t Type of Grout <br /> El Irrigation J4pprox. Depth F-1--Eastern Surface Seal Installed by I y <br /> Repair Work pone ❑ Type of Pump{ H.P. State Work Done I <br /> Well Destructiori ❑ Weld Diameter, Sealing Material (top 50'.) i I <br /> r <br /> A Depth Filler Material (Below-50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El---.'DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.► l <br /> Installation will serve: Residence Commercial— Other ? <br /> _ -Niirnber of'livin'units �< _ - ,'.. "�._ _-�` �' <br /> ;��—� - - - <br /> t g 'Number of bedrooms _ • t i <br /> Character'of soil to a.depth of 3 feet: - e Water table depth p� <br /> SEPTIC TANK s Type/Mfg Capacity +i No. Compartments' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Rtia ff, I Distance to nearest: Well Foundation 2 Property Line <br /> I Y 1 � <br /> i <br /> LEACHING-LINE_ No. & Length of lines �1� Total length/size �r i <br /> FILTER BED ❑ Distance to'nearest: Well Foundation��Property Line0 <br /> SEEPAGE PITS ❑ "Depth_ Size, ___.._ .._., Number. <br /> 1 <br /> SUMPSL ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ � <br /> hereby certify than I have prepared this application and that the-work will,-b6 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 signaturelcertifies the-fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person�iri5such.manner as to become su8ject1towoikman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followin6'­f certify that-in-the•performance,of 64 work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.", <br /> The applicant,must call forj I require inspect ons-Complete drawing on reverse side. <br /> Signed f -- k Title: )ate: <br /> f "tea FOR-D•EP�A�RTMEfVT OSI ONLY <br /> ` Application Accepted by Date /'#� V _;Area <br /> i( Pit or Grout Inspection by '- "bate ""�"'�' Final Inspection by <br /> �.. <br /> Y <br />' - Additional Comments: - - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ' ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to:-Environmenial Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE_ CK <br /> INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE T PERMIT`NO. 3' <br /> 1 <br /> +.EH 13-241REV.r/asl <br /> EH 14-26 <br />