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�f APPLICATION FOR PERMIT <br /> e i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1..2 <br /> QUIVtin p5 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. <br /> Job Address City tz E X,_ 1 Size <br /> 1/gyp PM <br /> 7 <br /> �� -7 <br /> Owner's Name C' Address - Phone r — �' <br /> Contractor Li Address l 7 , .License No. Phone_/ <br /> TYPE OF WELL/PUMP: W W E L WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i —PUMP INSTALLATION SYSTEM REPAIR 11 OTHER L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! <br /> FOUNDATION l Q AGRICULTURE WELL OTHER WELL PITS/SUMPS LD <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ,Mlndustrial ❑ Open Bottom ❑ Mantp'ca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing 5 ZkZl� Specifications <br /> F1 1 Public Ll Other C_1 Delft Depth of Grout Seal ��✓ Type of Grout_� <br /> + I I Irrigation Approx, Depth' I I Eastern- Surfce Seal Installed by- �C. <br /> `��, <br /> II Repair Work Done ❑ Type of Pumps S��t�-�'._-:,H.-P. 7TState Work Done i <br /> I Wel! Destruction E3 Well 17iametr r ';°Sealing-Material (top 50'1 <br />�. Depth - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is c <br /> available within 200 feet.) <br /> Installation will server Residence T-,Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> F DISPOSAL PONDS ❑ <br /> lik 1 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 <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: "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 r require ns. Complete drawing onreverse side. <br /> iSigned X �1 � Title: Data. l �T•� <br /> F1 FOR DEPARTMENT USE ONLY f-e rdi.w�11� <br /> 1 <br /> LF 4- <br /> Application Accepted by Date e <br /> PitGro nspection by # Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I f! FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> ' INFO CASH <br /> FJ <br /> ..EH c3-241pEV.iiHsi r 7 6 <br /> t EH 14-26 Q� <br />