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• _ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVED <br /> Triplicate)(Complete In Trip ) N p }�gp <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thaMere nOdbscribef3, li®p9,plication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weiupump and th I�q�grts,pf the an Joaquin <br /> Local Health District. ,1 PERMIT/SERVICES fT <br /> r <br /> c <br /> Job Address 4T O-C City ~ Lot Size PM <br /> 7� ►- =x.78 b <br /> Owner's Name AddressPhone <br /> JA 3 7 c.0 <br /> Contractor = f Address&4;4 i r O icense No m Phone�.�--� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION >; SYSTEM REPAIR ❑ OTHER 71 <br />'T "DISTANCE TO'NEA'REST:''SEPTIC TANK SEWER-LINES -`-'-"' DISPOSAL-FLD: .r- .P.ROI.:LINE, -,rr <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 3�DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1-1 Other fi ❑ Delta Depth of Grout Seal Type of Grout <br /> -—­ <br /> I I Irrigation —.-Approx.!Depth I 1 Eastern Surface Seal Installed by <br /> f <br /> Work Done ❑ Type of PDone <br /> Repair Wo Yq um C..�^ H.P. State Work P <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1, REPAIR/ADDITION I I DESTRUCTION I I (No septic system-permitted if public sewer is N <br /> available within 200 feet.) `I <br /> tT <br /> Installation will serve: Residence— Commercial— Other �I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:) Water table depth <br /> SEPTIC TANK LI Type/Mfg Capacity No. Compartments 117- <br /> PKG. TREATMENT PLT. ❑ -�' Method of Disposal (' <br /> Distance to nearest: Well Y 'Foundation Property Line C <br /> I LEACHING LINE ❑ No. & Length of lines { - Total length/size <br /> FILTER BED ❑ Distance'to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> _ SUMPS - D Distance to nearest: Well Foundation Property Line <br />: DISPOSAL PONDS ❑ <br /> I 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 Di1trict. <br /> Home owner or licensed agent's signature certifies the-following:z`_'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 m all #pr al uired inspections. Complete drawingo reverse side. f <br /> Signed /�'� Title: Date:�a—31 <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> I Application Accepted by �� � Data I Area >Id <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by ate <br /> a <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 45241 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BCK Y DATE PERMIT NO. <br /> INFO ,,S t �r �-r y <br /> +.EH13-24IREV.iih51 35 V' $ C h� l 74 0 " 2/e'er1 <br /> I <br /> EH 14-28 <br />