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... 1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT w :F <br /> } <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ^� I <br /> Tele hone (209) 466-6781 �► 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'N TAL H <br /> EALT <br /> (Complete in Triplicate) ENVIRaN�� Eta 6 ` �� I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herri3c' ifed. phis application is <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. I <br /> c� /�� l hr7 G UrS City Lot Size PM <br /> Job Address � I <br /> Owner's Name +! � Address 2Z!F'- f 7 S p�!� Phone 34, ,�J4LI <br /> Contractor <br /> x F-4 C Address + q i :X wd��Aermltl kCiLicenssee No.M 7 qif 7�Phone <br /> TYPE OF WELL' UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION f14.. SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public Cl Other F1 Delta Depth of Grout Seal Type of Grout <br /> V%1 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by_ <br /> Repair Work Done ❑ Type of Pump ! H.P. State Work Done'ro <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Below 501 <br /> r� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) J <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method o1 Disposal , <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l 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 Di$trict. <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 t ust call r all required inspections. Complete drawin on raver&e side. <br /> Signed X <br /> Ti Date: <br /> f/ FOR DEPARTMENT DISE ONLY <br /> [[[�« `�� <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by bate Final Inspection by Datey� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-63$5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. It <br /> INFO <br /> +.EH 13-24(REV.I/H 51 <br /> EH 1426 <br />