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I: APPLICATION FOR PERMIT <br /> + 1� <br /> Ii SAN JOAQUfN LOCAL HEALTH DISTRICT <br /> 1601 HAZELTON HAZE IT <br /> ON AVE., STOCKTON, CA 9 I <br /> Telephone (209) 466-6781 �N + <br /> l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I; (Complete in Triplicate) IErV�pp r11.� Irj�� <br /> Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein`d�scribed. 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 /> Local health District. <br /> ii <br /> Job Address 3��� Sb�i <br /> City Lot Size PM <br /> '��� <br /> Owner's Name t�G�`a+-�� Address hone 6 I� <br /> c � I <br /> Contracts apt a.a-� �`�(�,�� Addresse-ao'escense Nag{ 6-'Z-- Phone t <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 /> INTENDED USE TYPE OF WELL PROSLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 5[Domestic/Private ❑ Gra'vel Pack ❑ Tracy Type of Casing Specifications <br /> I"I Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Ii.- ­Approx. Depth (.I Eastern1 Surface Seal Installed by <br /> Repair Work Done-'-,LType of Pump.'ad H,P, State Wgrk Done 'r <br /> Well Destruction ❑ I Well Diameter Sealing Material (top 501 � <br /> Depth-( � Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Reside <br /> nce— Commercial_ Other _ <br /> Number of.living units: `.Number of bedrooms r <br /> Character of-soil to a.depth of 3 feet: Water table depth C <br /> SEPTIC TANK 0 T e/Mf <br /> yp g Capacity _/' No. Compartments <br /> PKG. TREATMENT PLT. ❑ III y -"4 Method of Disposal <br /> Distance to nearest: Well Foundation /+ Property Line <br /> LEACHING LINE ❑ No.11& Length of lines Total length/size <br /> FILTER BED <br /> LJ to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l l Depth SizeNumber <br /> SUMPS D Distance to nearest: Well Foundation °� Property Line '�- <br /> DISPOSAL,PONDS ❑ ,^ �'' <br /> I hereby certify•that'I have prepared this application grid-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 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 /> The applicant must c lifor all r uired inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> y <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by - Date Area <br /> Pit or Grout Inspection by h Date <br /> Additional Comments: Final Inspection by ate £Y <br /> ❑ Stk 466-6781 EI Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6366 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 <br /> ill <br /> FEE AMOUNT bUE AMOUNT REMITTED_ CK RECEIVED 8Y <br /> INFO CASH DATE PERMIT NO. <br /> +.EH 13-24 1REV.t/M 5) <br /> oU <br /> EH 14-28 <br />