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APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH <br /> i' DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 } J 19038 <br /> ` � f <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED £y�u�Rp E.!`ITAL HEALTH <br /> (Complete in Triplicate) FERC=lrZr����- ,- SER` ICES <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 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 /> Job Address <br /> City Lot Size PM <br /> Owner's Name �/.t�J <br /> Address � � �f f � <br /> J/�i�T Phone <br /> Contractor ,Address ���/ <br /> TYPE OF WELL/ �-�d )F�License No' 1�� S1 +�Phone l <br /> NEW WELL ❑ WELL REPLACEMENT ❑ one <br /> ❑ <br /> PUMP INSTALLATION,{ �,F,�,� � E?i�YST£M REPAIR ❑ <br /> DISTANCE NEAREST: SEPTIC TANKOTHER ❑ <br /> SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PR <br /> DP, LINE <br /> PROP. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> ❑ Industrial ❑ Open 80ti0m ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TYPE of Casing Specifications <br /> C]Other C.l Delta Depth of Grout Seal <br /> I 1 Irrigation --Approx. Depth I I Eastern nn Type of Grout <br /> Surface Seal Installed by_ <br /> Repair Work Done ❑ Type of Pump , � <br /> H'P' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material lBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIR/ADDITION I 1 DESTRUCTION ( i (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ CommercialOther available within 200 feet.) <br /> _ <br /> Number of living units: Number of be ms <br /> Character of soil to a depth of 3 feet: _ N u �J <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg . <br /> (� <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments v <br /> Distance to nearest: ellMethod of Disposal <br /> Foun Property Line <br /> LEACHING LINE ❑ No. & Length of i es <br /> FILTER BED ' . Total length/size <br /> ❑ Distance to rest: Well Foundation <br /> . Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> SUMPSNumber <br /> Ll Distance to nearest: Weil Foundation" i <br /> DISPOSAL PONDS ❑ Property Line <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 1 <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 � <br /> a em to an performance of the, for which this permit is issued, I shall not <br /> ploy y 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 EI 'ry all�reore �sPectio�nsComploterawing ort revers side. <br /> Signed X. r7 <br /> 7 Title: ' Date: <br /> / FOR DEP TMENT USE ONLY _ <br /> Application Accepted by / <br /> `fes '��,� <br /> /. �Finallnspection <br /> Date rea <br /> 01 <br /> Pit or Grout Inspection by J Date by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> PEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> +.Eli 13.24(REV.t i x 5) ��J - - c ,_, !`�-,r yy��.��,,.�rr�-,•//��Q <br /> EH 19.28 ✓ - - /—��46— <br />