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#� APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT( -) <br /> 1601 E. HAZE TON AVE., STOCKTON, CA PAYMENT <br /> (209) 466-6781 RECEIVED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APR <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"r oaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the RIr�prg,P��ti4 Agf t @S i�aquin <br /> Local Health District. PERM1 tt1SSERVL t l•I-! <br /> a Job Address Q�� " • _ d�M« City Lot Size f X ! / PM <br /> 1240 S V"&4h ''713 65'& 771Y <br /> Owner's Name ] Addr+e�s_s' /�� F- Phone <br /> tfu_tAy ' eJ1 �r�1i 054M �Qh� CA License No. _ 4 E23_0 'Phone 9/61695"-k6i <br /> Contractor � � � Address � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.'i LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 4�TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Iry <br /> LJIndustrial ❑h Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private lGravel Pack ❑ Tracy Type of Casing Specifications a'Q <br /> f7 Public 1-1 Other {1 Delta, Depth of Grout Seal I} <br /> Type of Grout er L me-4 <br /> I 1 Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wpell Diameter Sealing Material (top 50'1 (� <br /> Depth Filler Material (Below 50'i y1 <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l 1 (No septic system permitted if public sewer is Q <br /> 11 . available within 200 feet.I <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> 'iWater table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑'I Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ! LEACHING LINE ❑ No. & Length of lines i Total lengthlsize ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS { I Depth Size Number <br /> i SUMPS ❑'; Distance to nearest: Well Foundation Property Line l <br /> DISPOSAL PONDS ❑1 <br /> hereby certify that I have mpared 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 Q <br /> employ any person in such rrtenner 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 issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.,' <br /> The ap lic t must II for!all required inspections. Complete drawing on reverse side. <br /> i I c4/ n <br /> Sign d X Title: , Date:f <br /> F EPA USE ONLY 7 <br /> 3 <br /> + Application Accepted by Date S Area <br /> Pit or Grout Inspection by i ' Date Final Inspection ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copiers to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2", Stk., CA 95201 <br /> FEE AAAOUNT DUE AMOUNT REMITTED 9H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> Fs <br /> + EH 13-24 IREV,i/n 5) 3 y Siq 44LI <br /> EH 14-29 I <br />