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i <br /> APPLICATION FOR PERMIT <br /> 'qAS,\ NSAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> EP�� RECEIVED <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 466-6781 <br /> 14 <br /> t4aOP PERMIT EXPIRES 1 YEAR)FROM DATE ISSUED DC 198 <br /> J?lN9 � (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein de n is <br /> made in compliance with SanlJoaquin 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 City !_GC.� � Lot Size PM <br /> Owner's Name I' �' � � Address ��/ &� Phan <br /> Contractor Address 4 L 9.S�;f$ License No.:�Y fffT Phone l <br /> TYPE OF WELLIPUMP: �`i — NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER ❑ <br /> lig <br /> DISTANCE TO NEAREST: SEPTIC TANK _-. — SEWER LINES DISPOSAL FLD. POOP: LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE �YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation ZO EIL. Dia. of Well Casing <br /> [I Domestic/Private LGravel Pack ❑ Tracy Type of Casing •0��j' 2 Specifications �40 <br /> 1­1 Publico-Weld Other. �X Cl Delta Depth of Grout Sea] _240 Type of Grout <br /> i <br /> III Irrigation W� °Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Wel] Destruction ❑ Well Diameter Sealing Material Itop 50'1 �– <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> �! available within 200 feet:l <br /> Installation will serve: Relpspidence Commercial— Other <br /> ` Number of living units: �! Number of bedrooms <br /> iCharacter of soil to a depth of 3 feet: Water table depth <br /> ! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> I LEACHING LINE 01: No. & Length of lines Total length/size <br /> FILTER BED ❑I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l IDepth Size Number <br /> SUMPS Lill! Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑1 <br /> 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 Dii;trict. <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." 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 iIA(N, <br /> tion laws'of Californ ENVIRONMENTAL HEALTH DIVI ION <br /> F <br /> The applicant st all for all tions to drawing on reverse side. YECIAL PERMIT <br /> t SignedI _ Title: � Date: <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by —_._ Date r Area <br /> i <br /> Pit or Grout Inspection by `I� Date Final Inspection by�"�r`� — Data L� / <br /> Additional Comments: <br /> ❑ Stk 466-6781 '❑ dodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835=6385 <br /> Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> } I� <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> r INFO CASH <br /> +.EH 13.24(REv.t i x 51sq <aq <br /> EH 14-26I �� - <br />