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t <br /> t APPLICATION FOR PERMIT <br /> SAN JOP!QUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE.; STOCKTON' CA <br /> Telephone {209} 466-67.81 <br /> PERMIT EXPIRES 7 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 /> r' 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 /> Job Address v y City Lot Size PM <br /> Owner's Name(�4'd �7f �!'� Address Phone <br /> fi <br /> Contract <br /> t Address �b7 License No.zz�Z(e= Phone (v Slur <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r\J <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manieca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation __4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump H.P. State Work Done / <br /> Well Destruction LlWell Diameter Sealing Material (top 501 <br /> Depth I er Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Cl <br /> available within 200`feet.) <br /> �. <br /> Installation will serve: Residence '! Commercial °� Other <br /> Numbe of ooms �M - <br /> Number of living tunits:�� , h Water table deptf <br /> ' Character of soil to a depth of 3 fe '`--^ �k a%`'�_ - w <br /> SEPTIC TANK ❑ Type/Mfb- I _ Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ � Ali ' q Method of Disposal <br /> 13 " s <br /> k <br /> Distance to nearest\- Well Foundation Property Line <br /> I "J <br /> LEACHING LINE ❑ No. &:Length of lines �M Total length/size <br /> 1 FILTER BED E-1 Distance to nearest: Well Foundation, Property Line �- <br /> SEEPAGE PITS 65"Depth4 93S .Number I <br /> SUMPS ❑ Distance to nearest: Wkelt . Foundation Property Line Q f, <br /> DISPOSAL PONDS El it <br /> that the work will be done in accordance.witi4.Sari-Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application 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 tto 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 /> l The applicant m t call for qu''ed inspections. Complete drawing on reverse side. <br /> Signed I Title: �L'i Date: 1161 <br /> FOR DEPARTMENT USE ONLY t <br /> f _ <br /> ., Date � Area <br /> I <br /> opap"c <br /> ationAccepted by hi Grout Inspection by .1 e CFinal Inspection by ate <br /> T <br /> Additional Comments: <br /> ❑ Stk 466-Ml C7 Lodi 369-3621 ❑ Manteca 823-7104 C] 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 ASH RECEIVED BY DATE PERMIT''NO. <br /> } INFO <br /> -7pt o g-ly-g� <br /> + EH 13-24 iREV.1/e , <br /> 51 � <br /> EH 10.26 <br />