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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f (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 /> �/�] [' <br /> Job Address l�U - J. �41 �i�LJ•�L City Lot Size <br /> PM <br /> t1 <br /> Owner's Name �� d9:2E%_ -Address t� ,ZmPhone — �a <br /> Contractor s alkAddress 3� License No Phone <br /> TYPE OF WELL/PU NEW,WELL ❑ i. II, W LL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION`❑ -*' SY=ISPOSAL <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK�""�'SEWER'ONE5 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER-WELL-_ PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL QPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy *� Type of Casing Specifications `^} <br /> FI Public f:1 Other (71 Delta Depthof Grout Seal Type of Grout _ �J <br /> I I Irrigation Appiox. Depth I Eastern Surface Seat Installed by 1 <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth t=iller Material (Below 50') ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION I I DESTRUCTION 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 'Installation will serve: Residence—'"1 Commercial_ Other I <br /> _ Number of living units: -Numh'er of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTICTANK ElType/Mfg, Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> } <br /> LEACHING LINE 17-1 No. & Length of lines <br /> I <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Welt Foundation Property Line <br /> I <br /> k <br /> SEEPAGE PITS l 1 Depth :--_..- Number <br /> P _.--� Size,. ..-..._. __._...__. _ <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ii <br /> I hereby certify that! have prepared this application and that the work will be done'in accordance'with San Joaquin county ordinances, state laws, and M <br /> rules and regulations of the San Joaquin Local Health District. r.w <br /> Home owner or licensed agent's signature certifies the folt`Qwin <br /> g: "Icertify that in the performance of the work for which this permit is issued, I shall not <br /> amploy.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,t shall employ persons subject to workman's compensa- <br /> tion laws of California." ff <br /> f <br /> The applicant must Pfo quired spe ion omplete drawing on reverse side. <br /> Signed X _-.- — Title:_ - Pate: <br /> - �- - - <br /> ' F DEPA TMENT USE ONLY F <br /> £ e ' <br /> Application Accepted by ' a bate � Area <br /> Pit or Grout Inspection by ate Fin f F <br /> {.Insr�cti�n byV__ <br /> Datsi � <br /> AdditioAal Comments: 0�.� t rv�^ 9Z3�` SY <br /> ❑ Stk A 466-6781 ❑ Lodi 369-362342 <br /> 0 Manteca 1323-7104 ❑ Tracy 835-6385 V (� <br /> Applicant- Return all copies it Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMIT'NO. <br /> + EH13-21(REV::1/K$) :3✓ -0 ' - (,, r aG <br /> EH 14-26 t Q + + <br />