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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> l <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> Kornfete 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 /> r 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 /> Job Address mGz0Q0s1A1 1� ___ City Lot Size PM <br /> e., 1 � <br /> Owner's Name 1 + �. �� 1�`� ✓ Address 249 7 M k—. , `0 V IPhole <br /> V . �G S l <br /> Contractor Lv : 1 ` V M Address � ' 1.C�t License N,.B-51 Phone -7yS <br /> TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT L DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNOATrON AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation _ Dia. of Well Casing <br /> 0. Domestic/Priv to�-- ❑ Gravel Pack ❑ TT Cy Type of Casin Pv Specifications <br /> Public \OOC��, �� f. Other f-[ Delta Depth of Grout Seai "� Type of Grout N �. <br /> 1 I Irrigation Approx.`.Depth I I Eastern Surface Seal Installed by <br /> r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter! Sealing Material Itop 50T , <br /> Depth Filler Material 18elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted if'public sewer is <br /> availabie within 200 feet.) <br /> Installation will serve: Residence I Commercial_ Other ; <br /> Number of living units: Number of bedrooms �. <br /> i <br /> Character ofsodto a depth of 3 feet: Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments i <br /> PKG. TREATMENT PLT.❑ __ _ Method of Disposal ° I <br /> Distance t6-nearest, ___ Well .Foundation Property Line r i <br /> LEACHING LINE ❑ No. 8r Length bf-lines _ .-._ length/size <br /> _.. FILTER BED `• --. ❑ Distance tonearest:. ._ .Well Foundation Property Line <br /> t _ . <br /> SEEPAGE PITS I I Depth ; 4 —' Size Number-' <br /> SUMPS <br /> umber-- <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - r <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\C <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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 f 'ng:. <br /> aws "I certify that Wthe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion lC forri� <br /> The ap sca4tust call for II uir pections. Complete drawing o�n[rave <br /> r side.t► �[ f <br /> Signed Title: ]{ L/ _, Date: <br /> F R D ARTMENT USE ONLY <br /> Application Accepted by Date Area i <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: Y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environr6ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED cm iF <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> . EEH 1 -28 H 13.24Itt EV.I/NSI $qpp ,00 <br />�.`.: <br />