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APPLICATION FOR PERMIT 4. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i <br /> Telephone (209) 466-6781 <br /> l .PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br /> r i <br /> i �i <br /> i. <br /> (Complete in Triplicate) lI <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. y " II <br /> Job Address ��79 D . .V( , lr. Ci <br /> ty � Lot Size 11 <br /> I <br /> PM <br /> I i / A 1j <br /> I Owner's Name ,O Address U Phone - `f <br /> Contractor Address 25- fir1 ` I� <br /> icense No.��I�Phone ^! 5 <br /> TYPE OF WELL/PUMP: VNEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Ik <br /> .. r,•.r PUMP INSTALLATION ❑/ SYSTEM REPAIR ElOTHER ❑ .� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. / ' PROP. LINE <br /> a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS II <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> �l <br /> Domestic/Private >9,Gravel Pack �(Tracy Type of Casing pecifications <br /> C1Public C1 Other .1 ❑ Delta Depth of Grout Seal Type of Grout I <br /> ❑ Irrigation __-Approx.i Depth ❑ Eastern Surface Seal Installed by 2I� <br /> Repair Work Done ElType of Pump H.P. State Work Done ` ,] <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I (1Q <br /> available within 200 feet.i i <br /> Installation will serve: Residence Commercial— Other <br /> Number'of living units: Number of bedrooms LA <br /> Character of soil to a depth of 3 feet I Water table depth l� <br /> SEPTIC'TANK ❑ Type/Mfg+; Capacity No. Compartments 4 . <br /> PKG. TREATMENT PLT. ❑ `I Method of Disposal 4 <br /> Distance to nearest: Well Foundation Property Line M <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I� <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth f Size Number <br /> SUMPS ❑ Distance to_nearest: Well "' Foundation <br /> Property'Li ne" <br /> DISPOSAL PONDS ❑ i <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, acid <br /> rules and regulations of the San Joaquin Local Health District. i� <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."Contractors 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 wgdtman's compensa- <br /> tion laws of California." s.. <br /> The applica t m t call for all requ'ed ' pections. Complete drawing on rPlerse side <br /> • � ,,,� `,., fR <br /> �r <br /> Signed Title: <br /> O PART ENT USE ONLY y_ <br /> t <br /> Application AcceptedJ Date <br /> Area <br /> Pit or Grout Inspec' y Date lS Final Inspection by <br /> Additional Comments: . , �•,�"r i� <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.`, 401 Ir <br /> it 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT NO. I` <br /> + EH 13-241REV.ties) �� _ <br /> Ek 1429 E d— <br />