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" r ,APPLICATION FOR PERMIT <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FEB 2 0 10-291 <br /> 0-"'291 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ° Telephone (209) 466-6781 <br /> ENVIRUNNiENTAL H WWiW IT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERMIT/SERVICES ' <br /> (Complete in Triplicate) <br /> i 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 /> F[ Local Health District. ' <br /> Job Address,C 3 3 S-�) 'I• t 7� - City Lot Size PM J <br /> Owner's Name ^ ?X�4_� Address 11) Phone. <br /> Contractor+:_lQ�'�` Address -� ` License No/ 7 _ Phone�� ca" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial—-._ ❑.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> a Domestic/Private Ll Gravel Pack fl Tracy Type of Casing Specifications <br /> I` I'] Public ❑ Other e ❑ Delta Depth of Grout Seal Type of Grout_—_ <br /> ' <br /> I Irrigation —, ..Approx. Dep I I Eastern Surface Seal Installed by <br /> Repair Work Done L-�" Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> t - mrDepih -Filler-Material-I8alow-503 - <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION 1 1 DESTRUCTION 1 1 lNo septicisystem permitted if public sewer is �11 <br /> + available within 200 feet.) <br /> f Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> { <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J <br /> PKG, TREATMENT PLT. ❑ '� Met' d of Disposal <br /> L Distance to nearest: Well Foundation Property,Line7 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well I F- Foundation Property Line <br /> SEEPAGE PITS 1 1 Depth Size ; Number <br /> SUMPS I_I Distance to nearest: Well Foundation Property Line Q <br /> DISPOSAL PONDS ❑ <br /> 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 /> y 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 employipersonssubject to workman's compensa- <br /> tion laws of California." i <br /> The applicant +st c II for r All required inspections. Comples a drawing on reverse side. ? <br /> Signed X __- Title: Date: / 6?J 9 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date F Area <br /> 12/Y <br /> d <br /> Pit or Grout Inspection by Date Final Inspection by� J//�///f�'-�C�r-r/ Date l� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 635-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. <br /> r.EH 13-21IREV.+/x51 < a <br /> EH 14-28 !!! f <br />