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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA t� / <br /> Telephone (209) 466-6781 l <br /> °PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 <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. f <br /> City of Size +�`r PM <br /> Job Addres - <br /> Iva. 4 rG 4i�� --.3 <br /> Owner's Nam <br /> Address Phone <br /> ,y�Gsy' <br /> Contractor .' Address License No. Phone <br /> TYPE OF WELL/PUMP`. - .- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR L1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE k <br /> .01FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE [TYPE OF WELL PROBLEM A A CONS UCTION SPECIFICATIONS <br /> ❑ Industrial s❑ Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑,Gravel Pack 12Tracy pe of Casing Specifications g <br /> F-1 Public i n Other -.. 'j ' 171 Delta De of Grout Seal Type of Grout i <br /> I I Irrigation '_Approx. Depth , I I Eastern Suriac Seal Installed by— <br /> Repair <br /> y Repair Work Done ❑ Type of Pump <br /> P r State Work Done <br /> Well Destruction ❑ Well '1 <br /> Diameter Sealing Material (top 50 <br /> _ <br /> t '.Depth l Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION alvailsepti cyst m permitted if public sewer is"- 7 <br /> S within. <br /> 200 <br /> will serve: Aesid nce Commercial_ Other j <br /> Number of living units: -Number of bedrooms .. ( n I <br /> Character of soil to a'de h of 3 feet: Water table depth ` ] <br /> SEPTIC TANK -i 0' 4k Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ❑ No. & Len gth.of lines Total length/size { <br /> FILTER BED ❑ •Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size Number t <br /> I� SUMPS r -❑ Distance to nearest: Well Foundation Property C ne _ <br /> DISPOSAL PONDS ❑ •i A ��� �� y ' <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 <br /> f the San Joaquin Local Health District. a -`f' x, —1 i <br /> Home owner or licensed agent's signatures artifies the following: "I certify that in the performance of the work for which this permit is issued, I.shall not ti <br /> rules and regulations or <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring.or sut_rcantracting signature t\ <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 lawsof Cakifor <br /> The applicant c forall equi a ns. Complete drawing on reverse side. ` <br /> } Date:Title: f �p <br /> Signed X £ <br /> [ FORD AFaENT USE ONLY <br /> Application Accepted by ( ' d1161 <br /> 4'12� 4 y tate <br /> Final Inspection by Date <br /> D on 1 j <br /> Pit or Grout Inspection by i 11 <br /> r Additional Comments: .. { <br /> . 's sem'z <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY D�/ATE �PE�RIM�IT'N^O. <br /> elm <br /> 7/Z37 <br /> +.EH13-24{REV-1/FS5� 3� 3--5- T �� <br /> EH 14-2e + <br />