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} r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �.; . [ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> . Telephone (209) 466-6781 ti <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ►Et==. 1. 198 <br /> M (Complete in Triplicate) <br /> ENVIR010ENTAL HEALTH <br /> Application is herebymade to the San Joaquin Local Health District for a permit to construct and/or install the work herein d cribgg on is <br /> ade in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Rrg�r�h 4,==1uin <br /> Locai Health District. <br />'i <br /> Job Address /" �� ��/ __ City ` Lot Size PM <br /> i Owner's Name' a� Address Phone <br /> Contractor "4�15; s dress C )cense No. �t7 f C Phone <br /> TYPE OF WELL/PUMP: t NEW WrNJX9 <br /> WELL R LACEMENT ❑ DESTRUCTION ❑ <br /> PUMPiINSTALLAT �1�.��L+6Y EM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEP4 TANK. SEWER LINE�'�, - - DISPOSAL FLD. PROP, LINE <br /> FDUNDATION fifG'tyLTURE WELL "OTHER WELL PITS/SUMPS <br /> E>W` INTENDED USE TYPI�.OF WELL PROBLEM AREA:CONSTRUCR TlOh7"S PECIFICAT10NS­­ ---- -� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia" of Well Casing <br /> Domestic/ F❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I . . <br /> ❑ Public Cl Other 11 pelta Depth of Grout Seal Type of Grout <br /> ----:-- <br /> I i Irrigation - Approx. Depth�,I��Ig E�astern Surtac Seal Installed by <br /> Repair Work Done ❑ p of Pump H_40111A _ _ State Work Done <br /> Well Destruction ❑_ Well Diameter Sealing Material (top 501 <br /> Depth l Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK-.-,-NEWiINSTALLATIONWORK-.-,- I 1 i REPAIR/AD6tTt011-rr-1)'E'STMMTrM--Y"173�septic system permitted if public sewer is <br /> 1 a ! vailable within 200 feet.► 6 <br /> Installation will 'serve: Residence ommercil r Other �` , ! I <br /> Number of living units:y Number of drooms t I <br /> Character of soil to a depth of 3 feet: f '�` Water table depth } �` <br /> iSEPTIC TANK ❑ Type/Mfg I �--�Capa¢ity r 1 No. Compartments <br /> I PKG. TREATMENT PLT.d I i , �� Method of Disposal <br /> Distance to st: Well oundate6n.. `�� Property Line i <br /> LEACHING LINE ( Cl ristanceLength of lines i `JTotal length/size �. -- , <br /> 'FILTER BED �', to'nearest::::; el! Foundation \�.�"'� ope�tine�^-4�=�-:•:-� <br /> SEEPAGE PITS I 1 DeOth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation _ Property Line O <br /> . - DISPOSAL-PONDS ❑. 3 _t� :_r - <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, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> I. 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:"contractor's•hiring,arsub't ontracting-signatuto <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 <br /> alifrnia.-- <br /> The applicant m I require ons. Complete drawing on <br /> I!I r G•` reyers sid <br /> Signed X Title: e. <br /> Date: � <br /> 1 �!gJ� <br /> ,1 <br /> f ' R DEPARTMENT USE ONLY <br /> 2 <br /> Application Accebted byx✓ 40E?tt Area <br /> Date 7'2 <br /> Pit or Grout Inspection by . Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-13781' ❑ 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. Bax 2009, Stk., CA 9501 <br /> . l <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> '} <br /> +.EH13-24(REV.rix5) GD <br /> EH 14-26 <br /> ) <br /> S <br />