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u• I <br /> », APPLICATION FOR PERMIT <br /> 6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 v' ✓ 1601 E. HAZELT ON AVE., STOCKTON, CA CC ke-�rV <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> s 1.J �- <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. <br /> / IBGJ T` ll� <br /> Job Address � z City Lot Site PM - <br /> 1. <br /> Owner's / Address r~`*Phone <br /> LLicense�No,.___ <br /> Contractor Address" ` Phone - <br /> .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,,❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR' ❑ OTHE�PITS/S`UMPS DISTANCE TO NEARESTSEPTIC TANK `SEWER LINES DISPOSAL FLD. 'FOUNDATION` AGRICULTURE WELL OTHER WELL _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION CATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia e I 1xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing %- Specifications <br /> E <br /> I I IPrricblic ation Cl Other <br /> e th I I Eastern 'Surface Seal Seal Type of Grout _. <br /> I p Iled`by' _ <br /> 1 Repair Work Done ❑ - pe of Pump I•t.P. �� State Work Done_ <br /> i aj r <br /> Well Destr ❑ Well Diameter Sealing Material(fop 501 <br /> i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION,[ I DESTRUCTIO 1 (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 ❑ T e'/Mf Ca <br /> yp g Capacity'y`) No.'Compartments <br /> PKG. TREATMENT PLT. ❑ E i3 _ , Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> P <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> T <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line e <br /> µ if <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Fouhdation Property Line r <br /> s. 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 the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The a licant mus r requill n . Complete drawing on reverse s 0 <br /> Signed X r Title:" iC�i- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date Area v <br /> Pit or Grout Inspecti by Date' Final InspectioQ by Date <br /> Additional Comments: ��1'l�►^� �— _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 _ ❑*Manteca 86-7104 0.Tracy-.835-6385- <br /> Applicant- Return,all copies to::Environmental Health Permit/Services 1601 E. Hazelton,Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVEDBYDATE PERMIT`NO. <br /> INFO <br /> + EH13-24(REV.I/R s) rZb 00 ! Jam.. t7/fG^y <br /> EH 14-26 <br /> �'�. <br /> 9 -%0-off = u y n of h4N-6 bz ,11 i�� <br />