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I <br /> APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> {Complete in Triplicate}, , k <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 r <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 I <br /> Local Health District. y I <br /> c�7 31►, ii z Of' 11 <br /> Job Address /s�72 /C� C- 4 <br /> 4 P /V 9/9/ <br /> City Lot Size p PM <br /> Owner's Name II —Address � �V <br /> Phone 4 <br /> 'S l S1 aALicenseS 7�/ <br /> Contractor Address a� No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES_ -DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS { <br /> ❑ Industrial ❑ Open Bottom ❑ Man ca Dia. of Well Excavation Dia. of Well Casing M <br /> ❑ Domestic/Private LD Gravel Pack ❑ acy Type of Casing Specifications <br /> ❑ Public ❑ Other Delta Depth of Grout Seal Type of"Grout <br /> ❑ Irrigation �.�pprox. Dep ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 1 <br /> Well Destruction ❑ Well Diame r Sealing Material (top 50'1 1 <br /> Depth ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION W�REPAI R/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 3 <br /> s available within 200 feet0 <br /> Installation will serve: Residence Commercial, Other , <br /> Number of living units: _J_ Number of bedrooms Z <br /> Character of soil to a depth of 3 feet: <br /> Water table depth r <br /> SEPTIC TANK i B�Type/Mfg Capacity l�,2) No. Compartments <br /> PKG. TREATMENT PLT.❑ t <br /> I �,� / Method of Disposal <br /> Distance to-nearest: Well WO N_ Foundation� Property Line <br /> i p <br /> LEACHING LINELL�No. & Length of lines a r Total length/size <br /> FILTER BED . ❑ Distance to'nearest: We �0 Foundation .20 r Property Line Zao r <br /> SEEPAGE PITS 'B'Depth5_,_Size Number <br /> Z 3 <br /> SUMPS ❑ Distance to.nearest: Well AV Foundation c2_0 Property Line <br /> DISPOSAL PONDS ❑ I <br /> fiereby-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 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 <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 issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> The applicant must call for 11d inspections.tCompletdrawing on reverse side. <br /> Signed Title: G J A)c IG' F Date: <br /> FOR DEPARTMENT USE ONLY 3{ . <br /> Application Accepted by .. J � ? Date. r <br /> ! t i Area <br /> Pit or Grout Inspection by ' rDate Final Inspection by Date <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LI'Tracy 835-6385 4 r� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009,Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT RfMITTED <br /> INFO CASH' RECEIVED 8Y DATE PERMIT N0. <br /> \ Y' <br /> do 1 <br /> -+ EH 13-244REV.1/951 <br /> EH W28 �/ � _ ��/f►t�� 1���7 <br />