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■ � w <br /> gri - APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> AVside �.g <br /> IM <br /> Job Address f y /City Lot Size PM <br /> rQ� �1 f ry / ��p[dd ess v 0� Phone �t'.�1�3 � <br /> Owner's Name,. f- <br /> Contractor . ►�+`�-'� +r �r � Addressr x 23 '•License No. ` _����hon <br /> � <br /> TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1V PUMP INSTALLATION ❑ SYSTEM PLEPAIR ❑ OTHfR ❑ / <br /> _ DISTANCE TO NEAREST: SEPTIC TANKi'?f� SEWER LINES ' DISPOSAL FLD.� PROP. LINE ^�' <br /> FOUNDATION ,��� AGRICULTURE WELLOv',,,,t�y�OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS if <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ZDomestic/Private' ❑ Gravel Pack'^-- ❑ Tracy Type of Casing L Specifications. <br /> I <br /> 17 Public nOther Cl Delta Depth of Grout Seal d� Type of Grout <br /> a' <br /> 17 Irrigation -Approx. Depth l I Eastern Surface Seal Installed by 4 <br /> i <br /> Repair Work Done ❑ Type of Pump State Work Done_ <br /> QWell Destruction 171. Diameter Sealing Material Itop 50'1 <br /> Depth 3W, Filler Material i8elow 50') <br /> TYPE OF SEPTIC-WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> s�Installatio rve: Res' ence! Commercial= -Other <br /> Number-of living units: Number of b dro ms <br /> Character of soil to a depth of 3 feet: Water It epth <br />? SEPTIC TANK— 01' Type/Mfg a Capacity o. Compartments .- <br /> PKG. TREATMENT.PLT. ❑ e Method of Disposal <br /> Distance to nearest: Well Fo n Property Line �[j <br /> LEACHING LINE 0' No. & Length of lines l Total size <br /> i` FILTER BED ❑ Distance oto neo Well Foundation Propert <br /> r _ <br /> h�/� iJ <br /> SEEPAGE PITS Depth -Size Number <br /> 5UMP5 C1 Distance to nearest: Well Foundation Property Line <br /> i OSAL PONDS ❑ <br /> 1 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 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 /> r <br /> The applicant m 13 for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Ou " u Date: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .Date 2 Area <br /> - pp p � t6 <br /> Yep "� Final Ins rfl <br /> Pit or Grout Inspectio y Da 1 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 DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. <br /> INFO H <br /> I + EH 13-21IREV.tiH51 .- <br /> EH 4-2ti fn,bG °�d,I:.>v °m'2, <br /> - 1 <br />