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! APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t < (Complete in Triplicate) <br /> Application is h y made to the San Joaquin Local ealth 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 /> r Job Address City Lot Size _/00 X/2 Q PM <br /> Owner's Name Address Phonw! ° <br /> J-v <br /> Contractor _ _ _ _ _ess _ License No.y=laj_ Phone ]/1 <br /> TYPE OF WELL/PUMP: rNEW WELL ❑+ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR LlOTHFR ❑ <br /> i _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - ` DISPOSAL FLD. -PROP.-LINE_^ <br /> i FOUNDATION AGRICULTURE WELL•€ z' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> s <br /> ❑ Industrial ❑ Open Bottom Q Manteca il)jq'bf ..,11,Excavation I Dia. of Well Casing <br /> } ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of CasingSpecifications <br /> O Public ❑ Other ❑ Delta Depth of Grout Seal 3 Type of Grout j <br /> ` ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal-installed by I { <br /> Sl- <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done I <br /> F <br /> ! ^�Well Destruction ❑ Well Diameter Sealing Material (top 501 � • r " � <br /> 4 <br /> ' Depth Filler Material (Below 50'1 i + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI�}{� ❑ PAIR/ADDIT N DESTRUC ON (No septic system permitted if public sewer is + <br /> j JM� "-- her. <br /> ��'tl � s available within 200 feeta.- <br /> _1�, Installation will serve: Residence_ Commercial �; f <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I <br /> f PKG. TREATMENT PLT. ❑ Method of---Qisposal ! <br /> Distance to nearest: Well Foundation Property'Line 'may <br /> f <br /> I , <br /> 1 LEACHING,L NE ❑ No. & Length of fines Total length/size <br /> a FILTER BEDS, ❑ Distance to nearest: Well Foundation Property Line <br /> `a I . <br /> 1 SEEPAGE PITS ❑ Depth -S ize Number <br /> SUMPS ❑ Distanoe to nearest:--Well' -­; `-Fodndation'm.." Property Line x <br /> DISPOSAL PONDS ❑ I ! I <br /> i I-hereby,cei,ify 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 thd'San Joaquin Local Health District. L �. r <br /> Home owner or licensed agent's signature certifies the foilowinq,,, iJ6ertify�that in the performance of the work for which this permit is issued, I shall not <br /> f employ any person in such manner as to become subject to vrorkman's.comperisation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following.''I certify that kffie performance of th4i46rk for Which thispermit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican s4 call for II required inspections. Complete diadfig.on;reverse side. I f <br /> Signed f : <br /> Title: Date:r <br /> FOR DEPARTMENT USE ONLY f <br /> 36 <br /> Appiication"Accepted by ( Date Area '-f r <br /> A Pit or Grout Inspection " Date - Final Inspection;by ate `I L � <br /> �.� Additibnal Comments: _._ " `� =G v ✓ ' 1Ap(1 'ZBrrt��Ep _ <br /> x ❑ Stk 466.6781 ��Lodi 369-3621 ❑_ anteca-823 7104 J ❑ Tracy 835-6385 <br /> A plicantReturn-allcopies to:Eiwlronmental Health Permi[/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE I <br /> 1 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.1/e 5} <br /> EH 14128 <br /> * <br />