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APPLICATION FOR PERMIT r F <br /> SAN JOAQLIIN LOCAL HEALTH DISTRICT <br /> sa �. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIFRES'9 YEAR FROM DATE 'ISSUED <br /> (Complefe in Tnplicate) <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. 1962 for well/pump and the Ryles and Regulations of the San Joaquin <br /> 'Local Health District. - ;yp t0 t'' •_ yr <br /> 4". <br /> 1Jt <br /> Job Address "i F 4' 4 "' City y °7 Lot Size PM <br /> i - Owner's Name Address- 4Q� Phone S((r <br /> Y s <br /> Contractor Address, _r Cicensb Np Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ kvWELLEPLACEME_NTa0'-- ~ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 13 ` `, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES s DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELC_s-'-Lt OTHER WELL PITS/4$UMRS '? <br /> INTENDED USE TYPE OF WELLPROBLEM{.AREA •CONSTff_LJCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom; '❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-, <br /> ❑ Domestic/Private ❑ Gravel Packf?... ❑ Tracy k Type of Casing Specifications <br /> I; D Public ❑ Other ❑ Delta F Depth of Grout Seal Type of Grout <br /> ❑ Irrigation — pprox Depth, ❑ Eastern: Surface Seal installed,by <br /> Repair Work Done ❑ Type of'Pump,• r H P. _ t. `-SYat Work Done <br /> _. <br /> Well Destruction ❑ Well Diameter i , Sealing Material (top 50'), - 3 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION..❑_ REPAIR/ADDITIONK DESTRUCTION ❑ (No septic system permitted if public sewer is O <br /> i available within 200 feet.) <br />` Installation will serve: Rest ence i Commercials Other <br /> Number of living units: Number of bedroom <br /> Character of soil to a depth_ of 3 feet: "S Water table depth <br /> SEPTIC TANK ❑ Type/Mfg1 Capacity o0, f No. Compartments k <br /> i PKG. TREATMENT PLT. ❑ # �� '_''= - -''---- -� M-�� �- - -Method of Disposal � <br /> Distance to nearest: §Well Foundation Property:Line I <br /> LEACHING LINE No. & Len gth of lines 2. Total length/size <br /> FILTER BED ❑ Distance to nearest: iWell Foundation�Z rt Property Line <br /> ,y <br /> SEEPAGE PITS ❑ Depth G. rSize Number �- <br /> SUMPS Distance to nearest: Well r Foundation /Af:J-_ ;Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify.that I have prepared this application and that the work will be done'6 accordance with Sari Joaquin county ordinances, state laws, and <br /> irules 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."Contractors 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 rppst call_f r II equirens ec' nc Complete drawing on-r verse side._ <br /> Signed i ' Title: Date: <br /> J!'FOR DEPARTApSENT USE ONLY <br /> ?Application Accepted Date Z'k Area <br /> Pit or Grout Inspection by Date 1 Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk_466-6781 _❑ Lodi 36.9-3621 ❑ Manteca 823-7104 I ❑ Tracy 8355-6365 " <br /> Applicant` Return all copies to:Environmental Health Permit/Service16-01--E.-Hazelton Ave:, P.o._Box 2009-Stk:_CA 95201 w <br /> 1 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH ~4. EC£IVED BY DATE PERMIT NO. <br /> + EH13-24[REV.1/8 51 <br /> EH 1426 <br />