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C I <br /> fF. { <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> y� PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> r <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 oro. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> l <br /> Local Health District. <br /> Job Address i r City h Lot Size—(fir PM <br /> Owner's Name Address , Rh rl _� Phone 1? 7 <br /> Contractor ��, ., Address © O>� 1I5� License No. D Phone <br /> TYPE OF WELL/PUMP: NEW WELL_❑ ► WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONS L] } ~� SYSTEM REPAIR ❑ OTHER ❑ �A <br /> DISTANCE TO NEAREST: SEPTIC TANK if •SEWERLAES DII POSAL FLD. PROLINE- <br /> FOUNDATIOJJ� AGfi1CULT/� URE WELL BOTHER WELL ��S/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL�IrNE� CONSTRUCTIOAPECIFICATIONS X <br /> ❑ Industrial ❑ Open Bottom ' ❑ N} teca Dia. of Well Excavation / Dia. of Well Casing <br /> ❑ Domestic/Private grGravel Pack 9r racy .4-" Type of Casing Specifications <br /> ❑ Public ❑ Other " `• /❑ Delta Depthhf Grout Seal _ Type of Grout <br /> [D Irrigation ---Approx.- Approx. Depth/ ❑ Eastern, P Surfhce Seal Installed by (1� <br /> Repair Work Don ❑ Type of Pump `H.P: } State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (t.-P1501 <br /> Depth Filler Material (Below 50")` <br /> TYPE OF SEPTIC WORK:w NEW INSTALLATION. REPAIR/ADDITION' DESTRUCTION ❑ 1No septic system permitted if public sewer is <br /> - r available within 200 feet.I ` <br /> Installation will serve: idents " Commercial �ltNumber of living units: Number of bedrooa e <br /> Character of soil to a depth of 3 feet: Water table depth �O f i <br /> { <br /> SEPTIC TANK Type/Mfg Capacity Z44 U a No. Compartments <br /> PKG. TREATMENT PLT. ❑ 0� r f Method of"Disposalr <br /> Distance to nearest: Well L 22 Foundation Property Line n __ i <br /> Jf <br /> LEACHING LINE No: & Length of lines Total length/size- <br /> FILTER <br /> ength/size FILTER BED ❑ .Distance to nearest: WbiI-ZL7 Foundation �.� ! Property Line `y <br /> SEEPAGE PITS ❑ Depth " Size . umber <br /> SUMPS ,X Distance to nearest: Well 1_7�>ir Foundation 4- Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 applicant must call for all required inspections. Complete drawing on reverse side. ti <br /> Signed X } _ Title:" Ctm A P. Date/ <br /> EPARTMENT USE ONLY <br /> Application Accepted.by FO - Date Area <br /> 40 <br /> Pit or Grout inspectiori-by Date Final Inspection by Date <br /> Additional Comments:•;.. <br /> ❑ Stk 466-6781 ❑ Jodi 369-3621 ❑ Manteca 823-7104 ❑ 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 <br /> INFO AMOUNT DU AMOUNT REMITTED A RECEIVED BY DATE PERMIT"NO. <br /> io ��[, <br /> + EH 13-24(REV.i/a 5) � �i:/J /� f W � <br /> EH 14-28 1 <br />