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7;. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Jobquin Local Health District for a permit to construct and/or install the work herein d �esc Ihii}�l�e�tSdn is <br /> made in compliance with San Joa uin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RulevivT ol ( oaquin <br /> Local Health District OfT <br /> Job Address _ City Lot Size PM <br /> Owner's;Name �d Address U • ;5,3-4. 7 7 Phone" <br /> Phone <br /> Contractor Address JiLGU License No. <br /> TYPE OF WELL/PUMP: j NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl <br /> PUMP-INS-TAtLA-TION SYSTEM-REP"A1R- - --- -- OTHER--a.•-- - <br /> DISTANCE TO NEAREST:"SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARi�\CONSTAUC,T,ION S.IiSCEPtCATIONS <br /> ❑ Industrial LI Open Bottom © Manteca Dia- of Well Excavation Dia. of Well Casing <br /> '�l Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications 4 <br /> M Public f Other t 171 Delta Depth of Grout Seat Y Type of Grout <br /> I I Irrigafion pprox-Depth^-(-l-Eastern--� Su1r a 5eafnfnstalled=by--�--P-----�' --- — - <br /> i o <br /> Repair Work Done ❑ pe f Pump ii � H.P- State Work Done <br /> i. T :✓ <br /> Well Destruction ❑ ell Diameter I Sealing Material (top 50 <br /> epth 71 =77`r( Filler Material (Below 501 <br /> TYPE OF SEPTIC,WORK:�JJEW INSTALLATION-[11 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> ( � <br /> available within 200 feet.i <br /> Installation will I). Rq'sidencei C(S?r,.tmercilbl Other <br /> Number of livingbti�its. I Numb r o�edrooms <br /> s <br /> Character of soil to a depth of 3 feet: "_ Water table depth <br /> SEPTICiTANK ❑ TypefllAfg + Capacity No. Compartments n <br /> PKG. TREATMENT-PLT. ❑ Method of Disposal \ <br /> [ Dist�ce to neerest: Well Foundation Property Line <br /> � <br /> LEACHING LINE ❑� No.11��gth of lines Total length/size <br /> t <br /> FILTER BED �� ❑J Distance to nearest: "Well Foundation Property Line <br /> I[I r <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS /` 1.1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL POND'5 ❑ <br /> I here4 certify thw 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 f <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 /> certifie�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 apblicant r I equire ns. Complete drawing on re [ <br /> se side. i <br /> Signed X Title: — Date: i5T <br /> I <br /> /7FQR ARTMENT USE XLY <br /> Applic!rout <br /> ion Accepted by r`-�//4 Date ^� { Area�� 3 <br /> Pit or Inspection by Date Final Inspection by U v to <br /> Addibinal Comments: — <br /> ❑ Stk 1 466.6781 ❑ odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant.- Return all copiel to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> l i <br /> FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH + 4�{ ] �j <br /> +.EH 1324(REV. /K 5] (!v r p G dad d� .3✓ <br /> EH 14-26 ` Ii <br /> _ J <br />