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1 <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 /> (Complete in Triplicate) - t3 <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. 1061 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.: <br /> Job Address <br /> ���V 1X0 I City Lot Size PM <br /> i [ 1 <br /> Owner's Name 'e—0141 ""' Address — R `— Phoneyg— <br /> Contractor Address- 5TO License'No. Phone ` <br /> TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ v SYSTEM REPAIR ❑ OTHERG� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FLD. ` PROP. LINE <br /> FOUNDATION I AGRICULTURE WELL —'-,'OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom { ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing 7 <br /> ❑ Domestic/Private El Gravel Pack i C Tracy Type of Casing E Ci Specifications <br /> F El Public + Ll Other ❑ Delta Depth of Grout Seal VType of Grout t <br /> II byi <br /> Irri ation ' =�4pproz. Depth El Eastern Surface Seal Installed by <br /> Re afi, k�Don6 .�❑ Type of Pump H.P. F i State Work Done- <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 . <br /> _ ,�. .. Depth Filler Material.[Below 501 <br /> s <br /> TYPE OF SEPTIC WORK NEW INSTALLATION ❑ .REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:, Residence_ Commercial_ Other <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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ £ I _ � ." Method of Disposal A <br /> + Distance to nearest: Well Foundation Property Line llv <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS L] Depth ` Size Number <br /> SUMPS _ } ❑ , Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS- ?❑ ' " <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. <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, 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 th work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> ! tion laws of Califor ia.". - x31 <br /> " <br /> The applies t call for-all re s n :Complete drawing on v side <br /> Signed ' Title: Date: <br /> t . <br /> R DEPARTEN7 USE O <br /> tom <br /> Application Accepted by .5 V�" 4 Date �r Area_ ~- <br /> �.a ` <br /> Pit or Grout Inspection b 4eC Date - dal Inspection by Date <br /> n.r. <br /> r Additional Comments, <br /> ❑ Stk 466-6701 ❑ Lodi 369-3621 :' ❑ Manteca 873-7104 ❑�-racy 835-6305 . <br /> Applicant="Return all copies to: Environrilental Health Permit/Services 1601 E.-Haz Itan Av P.O. Box 2009, S 5201 —o c� <br /> �s 6 . <br /> E %AMOUNT DUE AMOUNT REMITTED B PERMIT'NO.. <br /> + EH 13-24 MEV.1/051 7 IR <br /> ��� ~~ ✓�3�� `C)T <br /> EH 1428 <br />