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l ' <br /> - APPLICATION FOR PERMIT <br /> r } _- SAN JOAQUIN LOCAOhEALTH DISTRICT <br /> cd <br /> 1601 E. HAZE T ON AVE.,TSTOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'1`YEAR FROM DATE ISSUED`" . <br /> (Complete in Triplicate) f <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. s,. <br /> Job Address f :2 q3 1" /1'�G� '^ City `�Lot Size <br /> PM <br /> Owner's Name ) Address C11,.X_44 Z04te — (p <br /> Phone <br /> 4 r � r <br /> Contract V i Address `<.® toxLicense N � ��4-- Phone- 6D -54 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ _-,�DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER ❑ � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F,LD. PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r )` Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel pack ❑ Tracy Type of Casing ✓ Specifications <br /> ❑ Public C1 Other l <br /> ❑-Delta— _ Depth of Grout Seaf Type of Grout <br /> 11 Irrigation <br /> --Approx. Depth ,❑ Eastern Surface Seal Installed by <br /> ' Repair Work Done t❑ Type of Pump 1 H.P. State Work Done �. <br /> Well Destruction ❑ Well Diameter <br /> Sealing'Material (top 50')f <br /> Depth 1 r Filler Material (Below ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPA' DDITION Lor DESTRUCTION O (No septic system permitted if public sewer is <br /> �� f�" i /•i ' available within 200 feet.) <br /> Installation will serve: Res'dence Commercial Other <br /> t <br /> Number of living units: '_ NumbIer-o bedrooms <br /> , <br /> Character of soil to a depth of 3 feet: <br /> iJ <br /> Water table depth <br /> SEPTIC TANK t1Type/Mfg 1 <br /> CI -� �,._ �•-.. _ Capacity- No. Compartments <br /> L PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> �-Dikance to'nearest: Well Foundation Z-22 i Property Line <br /> _/ <br /> LEACHING LINE IES �`No ,& Length of lines _�%� �� Total length/size Z <br /> FILTER BED ❑ Distance to-nearest: Well L4-n Found&ion "' a-" ,—Pi6o FCRy Cine-�Z­I_ <br /> SEEPAGE PITS CDepth, Size ' z Number <br /> SUMPS ❑ 'Distance to}}'nearest: Well/C�p Foundation I O Property Line ' <br /> DISPOSAL PONDS ❑ <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 Localhiealth District! <br /> Home owner or licensed agents,signature,ce&ies the followin}g: "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."Contracior'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 /> � E <br /> PRquire inspections. Complete drawing on reverse s' e. <br /> Thea licant ust call far all I <br /> Signed <br /> 9 Title F--_ Date: <br /> A,�t- �� <br /> FOR DEPARTMENT USE NLY ; <br /> 1 <br /> _Application Accepted by !---- _ - - Date Area <br /> Pit or Grout Inspection by ate Final-Inspection by Date /J���J�S— <br /> Additional Comments; <br /> ZI <br /> ElStk 466-6781 11Lodi 369-3621 ❑ Manteca 823-7104 ElTr ca yo-`835-6385 tt <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Pox 2009, Stk., CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED_ CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH13-24(REV.1/85) - Qp r3r <br /> EH 14-28 <br />