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10 <br /> ' APPLICATION FOR PERMIT <br /> C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.601 E. HAZEL T ON AVE., STOCKTON, CA <br /> r <br /> Telephone (209) 466-6781 <br /> 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Hearth District for a permit to construct and/or install the work herein described.TMs.application is <br /> t made in compliance with San Joaquin County Ordinance No,549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. n ' B <br /> Job Address,L3 L/o '1 � >�✓ city �C t r Lot Size <br /> PM <br /> Owner's Name <br /> ddress. rU,{_ -1 dn�.Q� � phone D <br /> (s f © r �­y <br /> Contractor / <br /> Address Lrcense No.1 ��__ 3 7 3 Phone � 10 <br /> TYPE OF WELL/PUMP: NEW WELL i?' w WELL REPLACEMENT ❑ <br /> DESTRUCTION <br /> PUMP INSTALLATION 61," SYSTEM REPAIR ❑ OTHE <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LIi ES -2 oe DISPOSAL FCD. PROP. LINE S <br /> FOUNDATION �D _ AGRICULTU13E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA F CONSTRUCTION SPECIFICATIONS <br /> ❑industrial ❑ Open Bottom ❑ Manteca pia. of Well Exca ront� <br /> Dia. of Well Casing <br /> L3Domestic/Private 9KGravel Pack ❑ Tracy Type of Casing Specifications <br /> Plublic ❑ Other ❑ Delta Depth of Grout Seal � I <br /> Type of Grout <br /> ❑ Irrigation ---Approx. De D Eastern urface Sear Installed by d a0 <br /> Repair Work Done P- Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter Searing Maferial (top 501 <br /> Depth Filler Material (Below 501 <br /> E OF SEPTIC WORK.: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -t;' <br /> available within 200 feet.) <br /> Installation wr e: Residence Commercial Other - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 e Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearestF Werl oundation ' <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines al length/size ; <br /> FILTER BED ❑ Distance to nearest: Well 4oundation <br /> rty Line <br /> SEEPAGE PITS ❑ Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> f. <br /> r 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 cerfife'S46 following: "I certify that in theperformance of the work for which this permit is issued, E shall not I <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 workman's compensa- <br /> tion laws of California." <br /> The applican ust 11 for all r d inspections. omplete drawing on revers-e-side. I <br /> Signedr <br /> `'"'Titre• / <br /> Date: <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by V Date_- Z —8t' Area Z <br /> Pit or Gro Inspection by Date 3/5 Final Inspection by Date 2-2-k6 <br /> .Additional UrnmArim /32;r eee <br /> ❑ Stk e <br /> 466-6781 C7 Lodi 369 3621 ❑ Manteca 623-71 ❑ Tracy 835-6385 -Ar� se hu- frkr k. <br /> Applicant- Return all copips�: Environme al eatth Perm- ervices 1601 E. Hazekon Ave., P.O. Box 2009, tk., CA 95201 <br /> (J <br /> FEE AMOUNT DUE AMOUNT REMITTED E <br /> i INFO CASH RECEIVED BY. DATE PERMIT`NO. //' <br /> +EH 13-241RIEV.i/651 6c� <br /> EH W26 . 10Q�`�CA <br />