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tAPPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA �1 <br /> Telephone (209) 466 6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED SEP 2 7 1588 <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> his application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew p�T nj tyf1Ql<5 <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 7- /� City . Lot Size PM <br /> Job Address ^Cr�r� <br /> tltl ddress / '✓` !� L �'Yhone <br /> Owner's Name /7 <br /> \ Gf./99 -L Phone ' <br /> Contractor >N5 Address ��d License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION )a2 pVcEaYSTEM REPAIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS; —I <br /> j <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS t <br /> 0Industrial.— _ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia.1of Well Casing <br /> ❑Domestic/Private it Gravel Pack ❑ Tracy Type of Casing 1'""�"�-- ._.S.Pecifications <br /> ❑ Public [. ¢ n Other 1=1 Delta}, ,,'-Depth of Groutj'�eel 'f - 7ype of Grout - <br /> I 1 Irrigation �Approx. Depth I 1 Easteii ° f� Surface Seal Installed by a rIT, <br /> !` ! <br /> Repair Wor 'Done—❑ Type of Pump H.P ' �- State Work4)one <br /> ; , ; Xz <br /> h Weil Destruction D Well Diameter Sealin;3 Mate{rial atop 50'.1 } 1 I <br /> Depth j Filler Material IBelow 5t7'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAM ADDITION l i DESTRUCTION l I (No septic systemithin-200permitted if public.se'wer is <br /> ` '� :available-vu ,feet.l <br /> Installatibn will serve: Residence _Commercial_— Other '� _ •�- - <br /> Number of4living units: Number of bedrooms ' t <br /> e <br /> Water table dpth t <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK `� - ❑.- T.y a/Mfg _ �u���. Capacity �� _No- Compartments } <br /> PKG. TREATMENT PLT,.❑ Method of Disposal� � F <br /> !!! I '"` Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlslze t I <br /> ' tt <br /> FILTER BED ❑ ; Distance to nearest: Well Foundation Property Line -� <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> F I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin co>nty ordinances, stat laws, and <br /> 1 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 whichlthis 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'slcompensa- <br /> � tion laws of California.- <br /> 4 The applicant o ail req tions. Complete drawing on raver a side, <br /> Date: <br /> Signed X r <br /> FOR DEPARTMENT USE ONLY <br /> t�� > Date ' �? ! Area <br /> Application Accepted by �� 1 <br /> Pit or Grout Inspection by Date Final Inspeby -!Date <br /> Additional Comments: k <br /> ❑ Stk 466-6781 © Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 _ <br /> 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av' e:`P`O-8 '2009, Stk., CA9520i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH -7 <br /> +.EH 43-24tREV.I/R5) <br /> EH 1426 <br />