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APPLICATION FOR PERMIT JW <br /> dSAN JOAQUIN LOCAL HEALTH DISTRICT EUMfw"l-l�*- <br /> 1601 <br /> E. HAZEL T ON AVE., STOCKTON, CA AUG Z 1 <br /> Telephone (209) 466-6781 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> L HEA <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. J I �_�p <br /> Job Address !��� �. > City ®'z'"'V Lot Size PM <br /> ttdt Owner's ddress 1. r,''Rhone'.- " <br /> Contract Address ! ense No. Phone <br /> TYPE OF WELL/PUMP: NVN WELL �,/ ELL REPL CEMENT DESTRUCTION <br /> e l' MP INSTALLATION Z1 SYST REPAI THERP <br /> k - �-- ����" -. b V c.�-r1_ -,, <br /> DISTANCE TO NEAREST:'SEPTIC T SEWER�fNES N - DISPOSAL FLD` 'PF( P LINE'"' <br /> FOUNDATION AGRICULTURE WELL `",OTHER VVELL: PITS/SUMPS <br /> ms -°- <br /> t INTENDED USE TYP F WELL PROf3L�A�AREAs-CTT CTION SPECIFICAfI /f <br /> ❑ Ind tial pen.Bottom ❑;hAanteca DraQf Ihlellx�avatian Dia. of Well Casing <br /> arr�esticlPrivate ❑ Gravel,Pack ajracy ;e' TYpejof Casing Specifications <br /> f i'l Public '[�l fltFiet f�Deha -.-:Depth of Grout Seal Type of Grou ._. <br /> ' I I Irrigation �pt�Approx. De 1.l Eastern 'Sur aL`e'Seal Installed by ' <br /> I Repair Work Done ❑fj^Te of Pump _ 9-- H.P. `� .. State Work#Done _ <br /> .. . _._ . _ _a„ <br /> Well Destruction Well Diamete � _. Sealing Material (top'�0') <br /> Depth h Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (;No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence Commercial— Oih'sr•�� \ <br /> Number of.living units: r,Number of bedrooms <br /> Character,01 soil to a depth of 3 feet: 'Water table depth. <br /> SEPTIC TArJK1 ❑ Type/Mfg Capacity t 7-� o. Compartments <br /> PKG. TREATMENT PLT. ❑ _ ,Method of Disposal <br /> Distance to nearest: Well Foundation Prope.ty Line <br /> E <br /> t' �;. ` <br /> I •LEACHING LINE 171 No. & Length of lines - C`. .,� Total leng-ith%size <br /> g FILTER BED LI Distance to nearest: Well \Fo ndation PrrnnArty Line <br /> + SEEPAGE ITS i I Depth Site Number <br /> SUMPS. � `Lq-'"Distance�o nearest: - VVeII - -r`-'Finndauon �-: �� r�pe <br /> Pr <br /> 'Ry' me -,.--�--�-�_�� •-�•,:d <br /> DISPOSAL PONDS ❑ <br /> hereby coAify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health Datrict. <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 St all fo)all q 'ed i pecjions. Complete drawing on rse si e. <br /> Signed X 5. Title: j Date: '+ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date '2�~9� Area :2/ <br /> Pit orgrauInspection by to final Inspection byate� `�� <br /> Additions! Comments: <br /> d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY " DATE PERMIT NO. <br /> r.EH13-241REV.1/951 <br /> EH 14.28 /1•b'/ f <br /> r <br />