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17, <br /> APPLICATION FOR PERMIT <br /> a <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI�Iw (,2ej <br /> t <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. TFTs 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 /> F Local Health District. <br /> L4-r a t4 <br /> Joh Address 7 ! �y <br /> CityZ' Kj <br /> I <br /> � _ - t50l Lot Size � nL PM <br /> Owner's Name !(/1�F � Address <br /> �10Phone <br /> Contractor's Names- 1 License-No.w <br /> TYPE OF WELL/PUMP: -- - Phone <br /> NEW WELL WELL REPLACEMENT DESTRUCTION \ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK &20-9,7C OTHER El <br /> LINES - DISPOSAL FLD/t &�F PROP. LiNEl JJ <br /> FOUNDATION AGRICULTURE IIiIEL! OTHER WELL <br /> � � PITS/SUMPS <br /> INTENDED USE •�.C�tr , <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ ,�! 5 , <br /> Domestic/Private Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ❑ Public Type of Casing h Specifications <br /> ❑ Others ❑ Delta Depth of Graut Seal 1 <br /> ❑ Irrigation Type of Grou <br /> - -Approx. Depth <br /> ,1� ❑ Eastern Surface Seal Installed by <br /> Repair Work Done I Type of Pumpr� H.P. k- <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Mateeial (top 50'1 <br /> Depth �- ��Q Filler Material (Below' 50'1 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTiO (No septic system permitted if public sewer is ; <br /> installation will serve: Residence_ Commercial— Other `tel vailabie within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ t <br /> Method of Disposal -� <br /> Distance to nearest: Well Foundation Property Line > <br /> I <br /> LEACHING LINE ❑ No. &-LengtGf lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> p j <br /> SEEPAGE PITS ❑ Depth �'— -- - - -- — -- - �.-� <br /> p Size ! Number j <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation 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 <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 <br /> employ any person in such manner as to become subject to workman's compensation laws of'California."Contractor's hiring or sub-contracting rmit is issued, lsigna not <br /> turre <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws of California." ! p y persons subject to workman's compensa- <br /> tion <br /> applicantca for all required 'nspec' nom ate Ing on' verse side. <br /> Signed Title: y <br /> Date: 1 <br /> ,Q FOR DEP A TMENT USE ONLY ' <br /> Application Accepted by �!/\ <br /> Date f ` Area <br /> Pit or rout I spection by Date— <br /> Final Inspection by Date <br /> Additional Comments: -_ <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8364M <br /> Applicant- Return all copies to: nvl viron-ment 1 Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009j-'Stk., CA 95201 <br /> FEE - <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> CASH DATE PERMIT"N0. <br />+ EH 13-241REV.101831 �j. or _ `�� `f <br /> EH 1426 {� � • r � •�1(4, <br />