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PERMIT— <br /> O <br /> APPLICATION FOR PER <br /> _ , -_.� <br /> SAN J.OAQUIN.'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 applicationis. V <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. <br /> F Job Address PJ <br /> City Lot Size &At< PM"' <br /> ! ,,,,...Owner's-Name ! � �. ell, Address Zo 14J,d+1A*I ' <br /> i - - �,-•- -- - - ._ . - -- <br /> Contractor's Name /4 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL f❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �"•, <br /> PUMP INSTALLATION El <br /> �J SY,STEM_REP_A1R_❑,,� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 6NES DISPOSAL FLD, PROP. LINE <br /> .. -T-- —_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA'' CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom +!4 ❑ Manteca Dia._of Well_Excavation Dia. of Well Casing <br /> ❑ Domestic''/Ptivfte ❑ Gravel Pack ❑ Tracy 1 Type of Casing Specifications <br /> I ❑ Public 'C❑-Others- <br /> ` ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irri d-ion `' <br /> I. 9 >'�'��pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done © Type of Pump - H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 1 <br /> Depth Filler Material (Below,50'1` <br /> a TYPE OF SEPTIC WORK: NEW INSTALLATION IN REPAIR./ADDITION-❑'-""DESTRUCTION-©-(No-septic.system permitted if public sewer is <br /> available within,200 feet.) f <br /> ( Installation will serve: Residence)—< Commercial_ Other <br /> Number of living units: l .Number of—bedrooms 4 <br />' Character of-soil to a depth of 3 feet: Water table depthf� <br /> I SEPTIC TANK, 1:0 Type/Mfg Capacity "'"""'No:Compartments <br /> PKG. TREATMIEN7.PLT. ❑ i _ <br /> I �.��; - -.r..�....._ i� i� y Method of DisposaIl <br /> Distance to nearest: we Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines �' i 'y=" qO <br /> Tgtal length/size ' 2 � <br /> FILTER BED ❑ 'Distance to nearest: WeII Foundation aS <br /> Property Line 11 <br /> 1 SEEPAGE'PITS ❑ Depth Size Number <br /> SUMPS j ❑ Distance to nearest: Well Foundation Property Line <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 laws, and } <br /> rules and regulations of the San Joaquin Local Health District. <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 <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 California." <br /> The applicant must call fo I require ' spection mplete drawing on reverse side. <br /> Signed !Title: <br /> Date: <br /> f- <br /> FOR DEPARTMENT USE ONLY1. <br /> a Application Accepted by <br /> Date I <br /> t Area <br /> Pit or Grout Inspection by Date Final Inspection by pie Z' (' <br /> Additional Comments: <br /> u <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 flracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> -•FEE­F• CK.#....�.,- - <br /> INFO OUNT D E AAlIOIJiVT REAilll rED }r t ,CASH RECEIVED-BY""" _,,PATE" `"­PER MIT'NO <br /> + EH 13.24(REV.10/831 ' <br /> EH 14-26 <br />