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S <br /> APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MARf <br /> ' (Complete in Triplicate) <br /> 937 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the NVIRMENITAL HEALTH <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the,Rut �Q +gyp i <br /> Local Health District. 81stf 1�e latfons of th`eSanication is <br /> Joaqu n <br /> I Jab Address -" r�uo <br /> , <br /> City ✓ -+ Ot Size <br /> u PM <br /> Owner's Name Q I� 1 (s �gddress } if L A JZ4F ? <br /> -l Phone t> �= Q <br /> Contractor's Name )C, W <br /> TYPE OF WELL/PUMP: License No. /2.., <br /> NEW WELL ❑ Phone G <br /> WELL RE CEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1� SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 00 OTHER ❑ <br /> SEWER LINES — DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP, LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man — <br /> Domestic/Private teca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Gravel Pack ❑ Tracy <br /> ❑ Public E3 Other Type of Casing Specifications <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth ❑ EasternType of Grout <br /> Repair Work Done ❑ Type of Pump S State Work Done <br /> dace Seal Installed by <br /> Well Destruction ❑ Well Diameter <br /> Seal t <br /> Sealing Materia! (top 50') z <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI R/ADOITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is " <br /> Installation will serve:;ResidenceCommercial Other available within 200 feet.! <br /> 4� <br /> Number of living units: <br /> F Number of bedrooms <br /> Character of soil to a d <br /> E <br /> epth of 3!feet: <br /> SEPTIC TANK ❑^" Type%Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity� No. Compartments <br /> %bistance to nearest: WeilMethod of Disposal <br /> Foundation Property Line_ ' <br /> LEACHING LINE ❑ ,No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> length/size <br /> Foundation_ Property Line <br /> " _ <br /> SEEPAGE PITS " ❑ depth <br /> Size Number <br /> SUMPS ❑ Distance to nearest: <br /> DISPOSAL PONDS ❑ Well Foundation�" Property Line " <br /> hereby certify that I have prepared this application and that the work will done in accordance with San Joaquin cou <br /> rules and regulations of the San Joaquin Local Health District. q rfky ordinances, state laws, and <br /> Home owner or licensed agent's signature certifies the following: ` 4 <br /> "I certify that in,the performance of the work for which this permit is issued, I shall not <br /> employ any pe n in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> certifies the fol o Ing:'I certify that in th rformance of the work for which this ermlt!s issued,I shall employ <br /> tion laws of C I'ornia." p p y persons subject to workman's compensa- <br /> The applica st call fo �`" <br /> it tion . Complete drawing on reverse side, <br /> Signed �� � <br /> Tule: <br /> i Date: <br /> C FOR DEPARTMENT USE ONLY <br /> Application Accepted by - "- " _,w--- _ __ _�__ +1 Q <br /> " Date o� vil Q__I-_'�,"-""`-•^�.-.-_.w <br /> Pit or Grout Inspection b I Area J <br /> y Date ✓ ' <br /> Final Inspectiononby <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 <br /> ❑ Manteca 823-7104 13 Tracy 835-6385 I <br /> Applicant- Return all copies to: Environmental"Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 9=1 <br /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> EH 13-2¢{REV,161931 PERMIT''NO. <br /> EH 1428 /Z� <br />