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r <br /> APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> a PERMIT EXPIRES 'f YEAR FROM DATE ISSUED <br /> t (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. 2- <br /> 3 Quy S� <br /> Job Address _-._...T� �. ���1�0 &eP4A1A:!tW.- city 7a­rY Lot Size PM <br /> Owner's Name &1U/` F' Address =� o�d7t/r+ ___ -_ Phone <br /> oat" Contractor Address I779B brr5�r .v License No. Phone <br /> t, TYPE OF WELL/PUA11P__ ; ,ry}r Y 6,.`cNEW WELL.[I WELL REPLACEMENT-❑. "�4D�STRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.'Ll OTHER LI qt <br /> "DISTANCE TO NEAREST: SEPTIC,TANK J SEWER LINES ''"' DISPOSAL FLP. ' PROP. LINE, yam, <br /> Its` i. � - <br /> � Y FOUNDATION AGRICULTURE WELL OTHER-WELL= PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> a. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications p <br /> FI Public 1-1 Other .E Cl Delta Depth of Grout Seal Type of Grout _ G <br /> I I Irrigation _.-Approx. Depth 1.1 Eastern Surface Seal Installed by _ S <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction Well Diameter Sealing Material Itop 501 <br /> Depth q/ Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> ' available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: — Number of bedrooms <br /> / r <br /> Character of soil to a depth of 3 feet: Water table depth r <br /> r f... <br /> SEPTIC TANK ElType/Mfg Capacity No. Compartments ,°1°.iµ' i`,•,t 1i,/?'�vT``a <br /> PKG. TREATMENT PLT. ❑ Method of Disposal' <br /> Distance to nearest: Well Foundation Property.Line � <br /> Gag <br /> n. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ 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 /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,�an <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." 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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call for <br /> ryall ired.inspections. Complete drawing on reverse side. <br /> ' Signed X a��// Z_� Title: Date:.. <br /> FOR R DEPARTMENT USE ONLY p �q <br /> Application Accepted by 5-�hdn Date �� ` ! Area C� <br /> Pit or Grout Inspection by Date Final Inspection by Date*/ef s r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑'Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO. <br /> ..EH 13-21(REV.1'/H 5) p"f� f-• <br /> EH 14-26 y <br />