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3Y70 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON-AVE., STOCKTON, CA <br /> .Telephone (26).466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED' <br /> {Complete in Triplicate} ,# <br /> Application is hereby made to the San Joaquin LocalHealthDistrict 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. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 7t" ''` City r Lot Size PM <br /> .�� _ Jt�t�. Rt �- <br /> Owner's Name � Address � t Phone <br /> Contractor '"`"ter" + Address SCF- License NO. 2-3 7 3 _Pho6_(6_C_9( <br /> TYPE OF WELL/PUMP: NEW WELL' ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout <br /> © Irrigation __4pprox.'Dep� - f© Eastern Surface Seal Installed by <br /> Repair Work Done � Type of Pump �"� H.P. State Work Dona - 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top <br /> Depth Filler Material (Below 501 I y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C1REPAIR/ADDITION L3 DESTRUCTION 13 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> It �J� <br /> r Installation will serve; Residence_` Commercial — Other x <br /> Number of living units: Number of bedrooms !' <br /> it to a depth of 3 feet: ` Water table depth <br /> Character of so p <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity ` iNo. Compartments <br /> PKG. TREATMENT PLT. ❑ kMethod of Disposal <br /> Distance to nearest: Well_._ Foundation ^Property Line <br /> ize <br /> LEACHING-UNEl- 'f- ❑ wNo.�•& Length-af-lines— — dotal lengthlI <br /> FILTER BED Eloun ati <br /> Distance to nearest: Well F � Property Line <br /> SEEPAGE PITS ❑ Depth : Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property-Line <br /> DISPOSAL PONDS ❑ \ <br /> I hereby certify that I have prepared this application and that the work wl -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."Contractor's 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 applica mus call for all quired inspections. Complete drawing on reverse side. <br /> }.�_,, _ Date: `- ` <br /> Signed e:_ i' "r v -1 , > r,., <br /> FOR DEP TMEUSE ONLY ? <br /> DA[ea' ' / <br /> Application Accepted by ate rz7 "-� (� <br /> I Pit or Grout Inspection by <br /> Date Final Inspection by Date"� �" <br /> Additional Comments: ,� JrF <br /> LD Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104---'' El Tracy 835-6385 � � �1 0 <br /> Applicant- Return all copies to: Envir6nimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> '., <br /> FEE AMOUNT DUE.' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ' ' �'r9I T-cQ R-X- S9 <br /> + EH 13-26(REV.$/a S) 5 ` cD Q <br /> 'r EH 7426 <br />