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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 <br /> ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> w (Complete in Triplicate) <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 I <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. r <br /> k i I <br /> Jab Address City �ot Size ,� PM <br /> 'i <br /> Owner's Name Address Phone <br /> Contractor ' Address License NoPhone <br /> TYPE OF WELL/PUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> # I <br /> _-'•3' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> --I TENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS $ <br /> *❑19dustrial ❑ Open Bottom ❑ Manteca Dia. of Weil.Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casinig Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> El �4pprox. Depth ❑ Eastern Surface Seal Installed by } <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done E Uf <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW,INSTA ❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septic "system permitted if public'sewer is N t <br /> '` available within 200 feet.).,_. <br /> Installation will serve:-4R'esiden a Commercial_ Other <br /> Number of living units:. jVurnber..of..bedrnoms -._ «.. -�. -- �- —,•» -_---d- "'"" "" ""'"�"' "' ! <br /> Character of soil to a d t of 3 feet: "} <br /> rt., Water table depth r <br /> SEPTIC TANK � •:�r' Type/Mfg # Capacity No. Compartments <br /> PKG. TREATMENT R47: iktfiod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ten. <br /> -tea.. <br /> LEACHING LINE fl No. & Length of lin s� Total length/size ; <br /> FILTER BED 77❑ Distance to nearest: Well _,Foundation -- —Property-L•ine� <br /> SEEPAGE PITS .lid' Depth +' <br /> ��—Size Number Ei <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line +r <br /> DISPOSAL PONDS ❑ I ` <br /> I�hereby certify that I have prepared this application and that the work will be done in accordance withtSan Joaquin county ordinances, state laws, and <br /> lules,and,regulations of-the San,gagy+n,Local Health District. .r <br /> Nome 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 iarson in such manner as to bac)me subject to workman's compensation laws of California.,"Contractor's hiring or sub-contracting signature <br /> certifies the, ollowing: "!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 ofCaia." ^t I <br /> The applica mu call for all-required in ` is . C plate drawing on reverse side. d <br /> �7 <br /> Signed Title:_G�` '1.��/��-- Date: <br /> r OR DEPARTMENT USE ONLY <br /> Application Accepted by f Date - 4'01I-67 Area CO i <br /> Pit o Groutnspection by Date Final Ins <br /> pection by Z� � Date a- � <br /> w <br /> Additional Comments: _ t . 4] <br /> ❑ Stk 4666789-^-- -D-L-odi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 <br /> t� <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMlT''N0. <br /> ♦ EH 13-24(REV.5/B 5} ' <br /> EH 14.28 L'�Z-1 <br /> O� I <br /> i 3 <br />