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APPLICATION FOR PERMIT <br /> SAN lIOAQUIN LOCAL HEALTH DISTRICT <br /> + 1604E. HAZELTON 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 LocalHealth 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 Ruies and Regulations of the Sen Joaquin <br /> Local Health District. J <br /> QU� �� Cit1�_kCt Size—_ _ PM <br /> Job Address <br /> .� f I� _ �} 9 Phone <br /> Owner's Name [ 1�li.L 1S)�- -`[�ddress `K,', <br /> 4r�t�to 35 W �' I 2,►2D �r�CIX 1Y_ _License No.qL�—Phone <br /> Address <br /> Contf actor � <br /> am <br /> TYPE OF WELL/PUMP: NEW WELLa �w L REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION A SYSTEM REPAIR F1OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK _ I� SEWER LINES DISPOSAL FLD-____ PROP. LINE <br /> FOUNDATION � �I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE_.,_ .TYPE OF-W,ELL�-.PROBLEM-AREA CONSTRUCTION SPECIFICATIONS <br /> — pia. of Well Casing <br /> ❑.Industrial ❑ Open Bottom C1 Manteca Dia. of WellAI <br /> Excavation _ <br /> N Type of Casin � Specifications <br /> Domestic/Private ❑ Gravel Pack Tracy 9 <br /> 'h "�T of_Groui <br /> `1-1 Public Cl Other f.°I DeltaP.th of Grout_Seal ' ` pe 1 - <br /> rrigation _.Approx. Depth I:� Eastern 'Suri Seal Installed by <br /> _Ryy.., n H p �� <br /> (Repair Work Done [� Type of Pump T�B�. State_Work Done <br /> II /Sealing Material (top 50'1 + <br /> Well Destruction ❑ Well Diameter �-` 9 <br /> Depth I� !Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l 1 DESTRUCTION 44­1No septic system Permtted if public se er is ,. <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commer���IciIal _ Other <br /> Number of living units: Number of beAloms — F G <br /> Water table depth <br /> Character of soil to a depth of 3 feet: ��' <br /> SEPTIC TANK LlType/Mfg �I _ Capacity No. Compartments <br /> Method of Disposal t <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Weil Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linea Total length/size . <br /> FILTER BED C3 Distance Distance to nearest: Well _ Property Line� <br /> - <br /> SEEPAGE PITS 11 Depth �� _Size ' _ Number — <br /> SUMPS O Distance to nearesti�� Well Foundation Property Line <br /> DISPOSAL PONDS- ❑ =__ = -' •r"_ _ _ ,.«- <br /> yI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin Local Health Dli trict. <br /> 11 Home owner or licensed agent's signature certifies the following: -J certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's ensation taws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the wo ermit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws piXalifornia." III` <br /> The apocant o ail r act' ns. Complete • <br /> �I. Tit " <br /> Date: <br /> Signed <br /> �I F. R DEPA TMENT USE LY l <br /> ' Date - <br /> Application ccept Y <br /> 7� i 5` Fs u D <br /> Pit or Grout Inspection by _� Date Final Inspection q A � <br /> Additional Comments: f <br /> ❑ Stk 466-6781 C Lodi 369-3621 GI Manteca 823--7104 El Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16301 E. Hazelton Ave., P.O. Box 2049; StVi Ct4i} l <br /> II f `I _ <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. <br /> M <br /> . EH13-24iPIV.rinse Cs <br /> INFO <br /> EH 14-26 qL <br /> III' - <br />