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I � <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <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. s <br /> Job Address City -/ Lot Size PM <br /> n N Y1 Owner's Name / t Address [? /��� Phon / <br /> i <br /> Contractor. — ss.-,-L./--A ..:_License-No .- .�_ ..,Phoney-1 7021 <br /> i 'iTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT„❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM•REPAIR❑ `OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK } '$EW9A LINES;., a DISROSAL`FLO. �'"N-PROP. LINE t <br /> I `r. "t'.:AIFOUNDATION S AGRICULTURE WELL ^OTHER WELL"N --"°PITS/SUMPS* � ° if- <br /> -y � <br /> INTENDED�USE' ;TYPE OF WELL PROBLEM AREA' CONSTRUCTION,SPTFICAT,IONSZ.y#°____ - <br /> i ❑ Industrial ❑ Open Bottom ❑ Manteca-./ Dia. of Well Excavatib-r�2 - .. ­�7� Dia. of WeIFCasinq:� t' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing :t Specifications <br />{ t}❑ Public ❑ Other A ❑ Delta Depth of Grout Seal It Type of Grout 3 } <br /> +❑ Irrigation r-°��-._Approx'Depth--"-'❑ Eastern--^'--`Surface Seal Installed <br /> Repair Work Done ❑ Type of Pump H.P. i State Work Done ' ... 4 <br /> Well Destruction ❑ Pell Diameter Sealing Material {top 501 <br /> Depth Filler Material Melo ') I ,' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-P'—DESTRUCTION-E] (No septic system permitted ifpublic sewer-is` <br /> available within 200 feet.) } <br /> Installation will serve: Residence C ercial f the, <br /> Number of living units: Number o e ! <br /> r Character of soil to a depth of 3 feet: Water table depth ' <br /> '4 is <br /> 1SEPTIC TANK ❑ Type/Mfg Capacity Y�: No. Compartments <br />` 1PKG. TREATMENT PLT. El Method of Disposal i ix <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Q_No_ ength of lines Total length/size t" <br /> FILTER BED �0 :Y Dist ce to nearest: Well Foundation Property Line �,•� ,�'� i <br /> SEEPAGE PITS, ❑ Depth �,°,��size _N bei r <br /> SUMPS ❑ Distance to nearest: Well /_,i�p�� Foundation Prop. y Line r'•'v <br /> DISPOSAL PONDS % <br /> ED s �Y �v �� <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, an <br /> rules and regulations of the San Joaquin Local Health District. 6 } <br /> 1 j Home owner or licensed'agerit'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 issued, I shall employ persons subject to workman's compensa-' <br /> tion laws of California." <br /> The applicant rppstC <br /> all for 44 required 'nspections. Complete drawing on reverse side. i <br /> Signed / $Titie: Date: <br /> OR DEPARTMENT USE ONLY e. <br /> _ f <br /> Application Accepted by - �. Date �""��� _ Aea <br /> Pit or Grout Inspection byDate i Final Inspection by Date i, <br /> Additional Comments: <br /> ❑•Stk-466-6781—. -0-Lodi-369-3821 - ❑ Manteca—V3=71104r'-'-`❑-Tracy'-'835 5 <br /> Applicant- Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r }/ CK <br /> FEER ., <br /> INFO AMOUNT DUE , '� AMOUNT-REMITTED CASH RECEIVED BY 3 DATE PERMIT NO. <br /> + EH 24{REV. <br /> W 1/e CJ <br /> 51 .� - � 1 //_.- fC .tom �J <br /> EH t428 0+ /YJ ” oC <br />