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II <br /> I APPLICATION FOR PERMIT ` <br /> ii SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> p 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) <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. II' <br /> Job Address a / 63-6 1 G� / - / - City Lot Size YG G PM <br /> Owner's Name _.T den ' " -- Phone 6 s i <br /> Contractor _ �` �I Address License No. 3oS Phone <br /> TYPE OF,WELL/PUMP:- I NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ,INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> ❑-Industrial ❑ Open Bottom ❑ Manteca �Dia?s-of Well Excavation Dia.iof Well Casing i <br /> ❑ Domestic/Private - ❑ Gravel Pack ❑ Trac y .�" Type�'of Casing ': Specifications <br /> f'l Public ❑ Other {vl Delta D�p"th of Grout Seat Type{of Grout__. _ ! <br /> I I Irrigation —.Approx. Depth € I Eastern <br /> ace stace Seal Installedt;by # <br /> Repair Work Done 173 Type of Pump f14 J- State Work Done <br /> Well Destruction ❑ Well Diameter }'Sealing Material flop 50') <br /> / ! f� -- V <br /> Depth '" Filler.Material {gelow 5.0P- <br /> TYPE <br /> 0� <br /> TYPE OF:SEPTIC WORK: NEW!INSTALLATIONil REPAIRYADDITION I I DESTRUCTION ! I (No septic system pgrmitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence v Comte rcial—, Other <br /> Number,of living units: II Number of dooms, <br /> Character of soil to a depth of 3 feet: = Water table depth _ <br /> SEPTIC TANK IUType/Mfg Capacity No. Compartments z- <br /> PKG. TREATMENT PLT. ❑ i - -�.,�_,..,,4 Method of Disposal <br /> Distance to nearest: . ._ We11 �s? Foundation r Property Liner <br /> LEACHING LINE RY- No::& Length.of Ii Total Total length/size l�� <br /> FILTER BED ❑ Distance to rlearast—. 1 Well Q f Foundation —... Property Line,%3 <br /> SEEPAGE'PITS IfYDepth IPI+5 Size Number <br /> SUMPS 0 Distance to nearest: Well /sYS-/ Foundation r Property Line f <br /> DISPOSAIL 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 k <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: '9 certify that in the performance of the work for which this permit is issued, I shall employ persons s y bject to workman's corrlpensa <br /> tion laws-of-California-.". <br /> - -�- ----� ----- ---�-^ u <br /> -'The applicant must call for all required spe tions. Complete drawing on reverse side. / Q <br /> Signed X i(� ' TitleDate: <br /> q; FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by Data �� A a 2, f <br /> it or Grout Inspection by Date - / Final Inspection by Date/lr �-�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 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 85201 I <br /> -1­--- -,FEE- AMOUNT'DUE- -""-AMOUNT"REM_1TTED" "CK" ""-RECEIVED BY--`""`DATE PERMI Np. <br /> INFO H <br /> ..EH13-244pEV.1./451 <br /> EH 14-26 '!. <br /> �l <br />