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r� <br /> APPLICATION.FOR PERMIT r,=-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> ` Telephone (209) 466-6781 # <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> q(Complete in Triplicate}. Lo/ <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 Nor 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> _ —•city Q G Lot Size PM <br /> Owner's Name '1 Address - - Phone <br /> Contractor Address-_-_ �„ C License No -ft Phone I&IT8 <br /> TYPE W.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (� <br /> PUMP INSTALLATION El _ SYSTEM REPAIR C1 OTHER C1 "11 t <br /> DISTANCE TO NEARES : TANK SEWER�LINES—;" ' DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> *—INTENDED-USE--"—TYPE-OF'WEL: —PROBLEMAREA UC'rONNSPECIFjCATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exc ti Dia.f of Zell Casing❑ Domestic/Private LJ Gravel Pack LJ Type of Casing S <br /> pecifi�tions <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r rout r <br /> ❑ Irrigation ,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of PumpH.P. State Work Done <br /> Well Destruction ❑ Well Diameter f- •---Sealing Material (top 50'1 tl . <br /> DepthFiller Material (Below 50') <br /> TYPEOF SEPTIC WORK: NEW iNSTALLATION< -�REPAIR7ADDITION ❑ DESTRUCTION ❑,(No septic system permitted if public sewer is <br /> ter,- <br /> available within 200 feet.I <br /> Installation will serve: Residence AL Cotmnercial— Other <br /> Number of living units:—I— Number,of bedrooms F, <br /> r <br /> Character of soil to a depth of 3 feet( �t E Water table depth /� r <br /> SEPTIC TANK F1Type/Mfgf _p .. ...w . �- pacty�� No. Compartments <br /> rw..... - <br /> PKG. TREATMENT PLT. ❑ tr <br /> `u,1�., A �G� Method of Disposal <br /> ` k• !Distance to"nearest: Well Founifation G✓ `. `Property Line <br /> LEACHING LINE O No s&-d6ngth of liries, Tota! I9'ngth/size F <br /> FILTER BED ❑ Distance to nearest WeilYVI2—9 Foundation Property Line <br /> AIA Z- <br /> SEEPAGE PITS ❑` De th-Y_' V 1,. ' i" <br /> p ! F Size Number <br /> SUMPS I ❑ - Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f 1 1 <br /> I hereby certify that I,have prepared;his application and that the work will be done in accordarice with San Joaquin county"ordinances, state laws, and <br /> rules and regulationsjof,the Sark Joaquin.taocai Health District. <br /> employHome owner or licensed a`gent's'`signature�certif;es the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> y person in.such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> + certifies the following:"I certify tha6the performance of the work for which this permit is issued, Ihall to <br /> tion laws of California?"� �f' �^ em P Y persons subje{ct to workman's compensa- <br /> - <br /> The applicant must call-f all r guired inspections.Complete drawing on reverse side. F <br /> - � « r t <br /> Signed X + s Title:' <br /> Date: <br /> I Date:, <br /> t <br /> FOR DE ARTMENT USE ONLY <br /> 4 Application Accepted by <br /> i ,t•t Date ` 0 Area <br /> Pit or Grout Inspectit by r 1 Date Final Inspection 6y ! Date <br /> g <br /> Additional Comments: V 4, . <br /> 11 Stk 466-6781 ❑ Lodi X69 3621 kr Manteca 823-7104 13 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O 1 Box 2009, Stk., CA 95201, I <br /> 9* <br /> s' <br /> y `y FEE AMOUNT-DUE•.R. _-A NT REMITTED»K" �K "••RECEIVED-BY'�" ""'`DATE"' 6— <br /> INFO"`" CASH._ <br /> r <br /> +EH 13-24(REV,17 a 51 <br /> EH 1428• r <br />