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APPLICATION FOR PERMIT , r.-A Tyr <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT :,� <br /> 1601 E.,HAZELTON AVE., STOCKTON, CA Na <br /> f. Telephone {2091 466-6781 4. fi ��!({ <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENvi:R lit: ;_T/�� HEALTH <br /> 4. C :, .., : `, (Complete in Triplicate? " <br /> `� � `I� �desbrtbeii1�llii_s application is , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work rein <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1861 for well/pump an the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 06 . <br /> �J . i City y Q Lot Size ' PM <br /> Job Address <br /> �+ Address "'�Y T �` Q Phone <br /> Owner's Name (�� <br /> /, YJ �`CL T, License No. 2f� Phone 1-79 l <br /> Contractor4'^"'' Address <br /> DESTRUCTION ElTYPE OF WELL/PUMP: N_EW WELL WELL REPLACEM_EN <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 71OTHER ❑ <br /> r <br /> DISPOSAL FLD. PROP. LINE. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /S U PS -•- -'" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO�911( pia. of Well Casin <br /> ❑ industrial ;&ravel <br /> pen Bottom ❑ Manteca Dia. of Well Excava n i �PackTracy Type of Casing Specificaromestic/Private ' Type of Grout <br /> ❑ Public ❑��..O��--t--her ❑ Delta Depth of Grout Seal <br /> Mpprox' Depth ❑ Eastern Surface Seal Installed by �Gt/�T�r <br /> ❑ Irrigation i j <br /> Repair Work Done ❑ Type of Pump <br /> H.P. .. State Work Done �l_1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth I Filler Material (Below 501) ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septi system permitted if public sewer is <br /> available s <br /> Installation will serve: Residence i Commercial Other d ► <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK El Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> a Total length/size <br /> LEACHING LINE ID No. &Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lin( <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: s. Well Foundation Property,Line .� - -^—� <br /> { <br /> DISPOSAL PONDS ❑ <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 Paws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> .ter <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, 1 shall not <br /> employ any 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 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 of Califor <br /> The applicant ust'011 for re it inspections. Complet drawing on r arse side. <br /> Signed Title:r Title: . iJ� Date: $$ <br /> E FOR DEPARTMENT USE ONLY <br /> 1. <br /> Date `� � Area <br /> Application Accepted by <br /> yam' r o? 0 Final Inspection by Date <br /> Pit c o t rispection by Date <br /> Additional Comments: J . <br /> ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> 835-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BYHDATE PERMIT"NO. <br /> F FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO+ EH 13-241REV.1/95/ <br /> EH 14-29 <br />