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r? <br /> APPLICATION FOR PERMIT , <br /> �. <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT : <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N I_ HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NV(RO�t <br /> FERMI <br /> -f TTIS/SERVICES <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. <br /> Job Address -{ 6 City Lot.Size PM <br /> Owner's Name � + � Address 0 67 Phon <br /> Contractor � 'r� Address 6 YC d- 14-9-ou License No/6 -2323 PhaneT 'r6.2s— f <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR N OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK`. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Eb Manteca Dia. of Well Excavation Dia. of Well Casing ; <br /> ❑ Domestic/Private ❑ Gravel Pack UTracy Type of Casing Specifications <br /> LlPublic 1711 Other Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth D Eastern Surface Seal Installed by �J <br /> Repair Work Done 4 Type of Pump -moi H.P. 1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth --- Filler-Material-(Below-501'_ - -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is <br /> available within 200 feet.} n <br /> Installation will serve: Residence_ Commert ial_ Other 1 <br /> Number of living units: Number of bedroloms <br /> Character of soil to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK ❑ TypelMfgf Capacity No: Compartments <br /> PKG, TREATMENT PLT. ❑ i1 Method of Disposal <br /> Distance to nearest: ( Well Foundation Property{Line <br /> LEACHING LINE ❑ No. & Length of-lines Total length/size.f <br /> FILTER BED ❑ Distance to nearest: j Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth -,Size' _ -,V•''•' t Number <br /> SUMPS ❑ Distance to nearest: Well Foundation -r� "Propert'y Line <br /> DISPOSAL PONDS ❑ I r' <br /> i <br /> I hereby certify that I have prepared this application land that therwork wUl-4b 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." Contractors hiring or sub-contracting signature i <br /> certifies the following: "I certify that in the performarice 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 t c for all re 'red inspections. Complete drawing on reverse side.i' 1 <br /> Signed X_ le: / Date: <br /> FOR iDEPARTMENT USE ONLY <br /> Application Accepted by / I Date P`' 6 Area v <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUEUNT REMITTED ` CK* RECEIVED BY DATE PERMIT NO. <br /> INFO �- CASH <br /> + EHIW24IREV.1/55) r �� <br /> EH 1428 <br />