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1 <br /> APPLICATION FOR PERMIT <br /> Wim" w -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> g. f 1601 E. HAZEL T ON AVL., STOCKTON, CA <br /> Telephone (209) 466-6781 ' <br /> R p <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 weal pump and the Rules and Regulations of the San Joaquin <br /> Local Health district. IJ. - <br />{ � 1C /V r� � �r/G� PM <br /> 14 C_ City Lot Si e <br /> Job Address C /7_ <br /> I _ ,p f17 q/y <br /> �� ! <br /> Phone �d I 'r2 r <br /> Owner's Name ✓ - Address <br /> I Contractor d_+drI —Address ` ��` �S �[l License No !�`� Phone_ <br /> l DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP,, _NEW WELL-L>Y' -,WELL REPLACEMENT ❑ l,. -� <br /> PUMP INSTALLATION I� SYSTEM REPAIR ❑ _ OTHER ❑ <br /> ` DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK "' SEWER LINES <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAf CONSTRUCTION SPECIFICATIONS A/ " <br /> ADia. of Well Casing <br /> ❑ Industrial ®'6pen Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casin 6�. Specifications <br /> F-1 Domestic/Private ❑ Gravel Pack J] Tracy f3 �^ <br /> Cl Delta Depth of Grout Seal Type of Grout `V <br /> I nPublic f 1 Other h <br /> I>}frrigation ��Approx. Depth,� <br /> I I Eastern I Surface Sea! Installed by { - V <br /> Repair Work Done ❑ Type of Pump _� --_ H. State Work Done <br /> k Well Destruction Ll Well Diameter Sealing+Materia! {top 501 <br /> Depth t Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11, REP_AiR/ADDITION I:I� DESTRUCTION 11 (No septic system permitted if public sewer is <br /> # available within 200 feet.) <br /> installation will serve: Residence Commercial Other ;J� <br /> Number of living units: Numbef of bedrooms <br /> l Character of soil to a depth of 3 feet: Water table depth <br /> -M — TANK--TANK—= ❑=�-•Type/Mf Capacity — No. Compartments <br /> g - _ - - E: <br /> PKG. TREATMENT PLT. 111 Method of.Disposal <br /> Distance to nearest: .Well <br /> .= Foundation y��` Property:Line - <br /> f <br /> 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 0 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 taws, 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 /> f. The applicant =foralld ins ctio s. Complete drawing on reverse side. f <br /> Signed X Title: r-J Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date.Date Area ? <br /> Pit or Grout Inspection byAa�Z Final Inspection b Date J" <br /> Ad itionaI Comments: ' <br /> /, Stk 466-6781 • odi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 <br /> C/Apolicant - Return all copies to: Environmental Health Permit/Services 1601.E..Hazalton Ave., P.O- Box 2009, Stk., CA 95201 <br /> ,r. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE f ERMIT'NO. F1 <br /> INFO [� / <br /> a.EH13-241REV.r/851 �C}! I.�\ <br /> EH 14.26 <br />