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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN,LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'll YEAR FROM DATE ISSUED t <br /> �- (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. t '' <br /> J '�//37 <br /> Job Address <br /> 0L Q city Lot Size <br /> • , -- 9 <br /> Owner's Name Address — Phone <br /> Cantracto <br /> rQ S'J Address � � License N %?0 Phone <br /> i WELL/PUMP: NEW_WELL ❑ WELL REPLACEMENT'D DESTRUCTION ❑ <br /> PUMP INSTALLATION,[] $SYSTEM REPAIR OTHER ❑ ; <br /> w �l `a� N <br /> _ DISTANCE TO NEAREST: TANK SEWER LINES! DISPOSAL FLD. _P-ROP. LINE _ <br /> FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROB EA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open,Bottom ❑ Manteca f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type Cass Specifications <br /> ❑ Public" 11 Other Q Delta ,Depth of Grout Seal Type of Grout <br /> .y <br /> ❑;Irrigation _--Approx. Depth ❑� Eastern SurfaGe,Seal Installed by r Ij <br /> Repair Work Done ❑ Type of Pump if*H.P. -= # State Work Done V` <br /> Well Destruction ❑ Well Diameter - -• Sealing Material (top�50'1 <br /> y Depth _ *1 Filler Material='Below 50'} <br /> TYPE OF SE IC WORK NEW INSTALLATIO REPAIR/ADDITION-011" ❑ (No septic system permitted if public sewer is <br /> I I ) �,,,.. , available within 200 feet.) <br /> Installation will serve: Resjdence/ Commercial Other r ' <br /> Numberlbf living units:77N Number of bed oom ! <br /> a 'f Water table depth ' <br /> Character of Tsoil.to a depth of 3 feet: a _ <br /> SEPTIC TANK �TypelMfg Capacity_ � - a No. Compartments <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ j <br /> Distance to nearest: Well Foundation a Property Line ? ✓� <br /> %� -- ' . <br /> LEACHING LINE � Na. & Length of lines � Total length/size 0 <br /> _ , <br /> FILTER BED 11 Distance to nearest: r .Welloundtion Property Line f <br /> SEEPAGE PITS Depth Size ,Number ' <br /> SUMPS ❑ Distance to nearest: WellN �Foundation Proper y Line ` <br /> DISPOSAL PONDS El4 C) y <br /> I hereby certify that I have prepared this application'and that the work will'be done in accordance with Sah Joaquin county-ordinances,'state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I ! g}' i `_4 't <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perrforfnanee of th 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."Cpntractar 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 AI shall'employ persons subject to workman's compensa- <br /> tion laws of California." E :1 t <br /> The applicant t call for all quired ' spectio Comple dra g on..re side �"! . ' <br /> Signe <br /> F R DEPARTMENT USE ONLY <br /> f�� Q <br /> Application Accepted by t Date �] <br /> pate !� 6 'Final Inspection by �. Date 64 <br /> / or Grout Inspection by _ <br /> 4 <br /> Additional Comments: <br /> ❑ Stk 466-6781 p.L-odiA 369-3621 ElManteca 823-7104 ❑,Tracy 8354M85 <br /> Applicant- Return all copies to : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " <br /> FEE _r. SXMOUNTIDUE AMOUNT REMITTED �CASN i i RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> EH 1324 IREV. <br /> EH 14-26 <br />