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APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE;.T ON.AVE., STOCKTON, CA <br /> r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1`YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) f�' <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 well/ and the Rules and Regulations of the San Joaquin <br /> Local Health District. ° <br /> r,Wl <br /> Job Address � r�N��� �� City "Ift-VIZ--4«Lot Size1 <br /> ' Owners Name ��S... �/ f 7I� t ' y <br /> Address Phone <br /> Contractor Rary A?0070� Address ��f� C9� Tf�L �� License No. Zcb`4�{� Phone -?6/d <br /> TYPE OF WELL/PUMP: NEW WELL ❑' `�- "WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑i 0.° '-SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES I 1 DISPOSAL FLD. PROP. LINE i <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` <br /> ❑ Industrial C]-Open Bottom ❑ Manteca Dia. of Well Excavatioria Dia. of Well Casing <br /> .«�. ..a. <br /> a ❑ Domestic/Private ❑ Gravel,Pack ❑ Tracy Type of Casing r - --- Specifications <br /> ❑ Public . ❑ Other , ❑ Delta Depth of Grout`Sdal^ ^" �- of Grout <br /> Depth Irrigation ' L.a... W <br /> 9 �pprox. Depth ❑ Eastern Surface Seal Installed by r <br /> Repair Work Done ❑ Type of Pump~` H.P.:. - State Work Done t r <br /> t Well Destruction ❑ Well Diameters Sealing Material (top 50') ? <br /> f <br /> ' Depth Filler Material (Below') y" `- ' `\ i <br /> a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ `REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> 1­ _._.:_,_` }1,,abailable within 200 feet.] <br /> Installation will serve: Residence— Commercial, Other yam y j <br /> Number of living units:�_ Number of bedrooms_..1 •• _ <br /> i Character of soil to a depth of 3 feet: <br /> Water.table depth <br /> SEPTIC TANK ❑ Type/MfgI ! Capacity "-Nd-.-Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> w - Method of Disposal (� <br /> Distance`to nearest: Well Foundation Property Line d <br /> LEACHING LINE / No. & Length of lines 47 �'` - <br /> # - Total length/size i <br /> FILTER BED ❑ Distance to nearest: ""Well-' 0su <br /> _Foundation 0 � <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size - ,Number <br /> SUMPS 0 Distance to nearest:. Well Foundation '� ._Property Line <br /> PONDS F1/DISPOSAL <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 laws, and r <br /> rules and regulations of the San Joaquin Local Health District. `t '- <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 ' tl <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 ce -fy that in the performance of the work for which this permit is issued,I shall employ <br /> tion laws of California. persons subject to workman's compensa- r <br /> " <br /> The applicant mus equ' d i s.'Complete drawing on reverse side: <br /> Signed Title: <br /> Date: <br /> FOR DEPAR ENT USE ONLY / <br /> Application Accepted by Date C7 Area <br /> EJPit or Grout Inspection by - Date Final Inspection by - Date <br /> Additional'Comments: <br /> ❑ 5tk 466-6781 ❑ Lodi 369-3621 ante 823-7104 ❑ Tracy 835-6385 d <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 CKRECEIVED BY DATE EZ, NO. <br /> TINFO CASH+ EH t3-241REV �/85Y -7V �+y+, <br /> EH 5428 <br />