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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s p <br />( 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED`` <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 /> F made in compliance with San Joaquin County Ordinance No.549 far sewage or No. 1862 for_well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 0 t City 5 <br /> ry, ot Size PM <br /> Owner's Namey S D�Z7�dress Phone - - <br /> i' <br /> d f� <br /> Contractor Address �� '- `License Nope: Phan �2& <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMYEN I ❑-- j DESTRUCTION O <br /> PUMP-"INSTA aTIUN-❑"` -------""-� J <br /> ,SYSTEM REPAIR OTHER>Q <br /> DISTANCE TO NEAREST: SEPTIC TANKQ <br /> " SEWER DINES DISPOSAL FLD. PROP. LINE <br /> r iii �! -�-f a <br /> ­FOUN646N AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> ❑ Industrial ❑,Open Bottom ❑ Manteca' Dia. of Well Excavation <br /> Dia.'of Well Casing <br /> Domestic/Private Gravel Pack Ll Tracy .' Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i ' <br /> L. p Type of Grout <br /> e ❑,Irri "tion <br /> F 9 f -Approx. Depth ❑ Eastern �ry lS}�rf Seal Installed by V ! <br /> �' f or i x J l� J� <br /> R_eparr Work one Type of Purnp H.P. s State Work Done I <br /> (Nell Destructio i� O Well Diameter Sealing Material (top 50') <br /> (Depth f Filler Material (Below 501 3 I <br /> TYPE OF SEPTIC WORK: `NEW INSTALLATION6❑ REPAIR/ADDITION ❑ DESTRUCTION Cl (No septic system permitted if public sewer is <br /> available within 200 feet: <br /> F nstallation will serve: Resid nce_s+_Commercial_ Other it <br /> Number of living units: Number of bedrooms t -- rrF <br /> Character f-soil to a depth:ofIfeet:1 . Water table depth <br /> SEPTIC TANK ❑;.:, t Type/Mfg Capacity I No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance tonearest: Well Foundation Property Line t \ <br /> r <br /> LEACHING LINE ❑ No. Length of lines <br /> _ g Total length/size <br /> FILTER BED= ❑;. Distance to nearest: Well Foundation Property Line I <br /> i t <br /> SEEPAGE PITS Q DepthSize 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 7with Sanr Joaquin county ordinances, state laws, d <br /> rules and regulations of the San;Joaquin Local Health District. .� �` <br /> r q •, �. � moi;. A ,. L t_�. <br /> Home owner or licensed agents signature,oertifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall no <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 cehify 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 st call or'4all r ui d ctions. Complete drawing on reverse side. <br /> Signed Title: <br /> Data: <br /> x FOR DEP TMENT USE ONLY ! Area <br /> ;Application Accepted by Date, <br /> Pit or Grout Inspection by i Date Final Inspection by ata__ 0_1 3 <br /> Additional Comments: <br /> ❑ Stk 466-6781 Ll Lodi 369-3621 '1 El Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies ta: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CAA 95201. <br /> INFO f AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. <br /> } <br /> + EH 13.241REV.r/B5) <br /> EH 14-26 5 �1 S, C),o <br />