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• APPLICATION FOR PERMIT <br /> �j SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> �Dn F � 1601 E. HAZEL T ON"AVE., STOCKTON, CA <br /> 3 Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .. .v4 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> * CMZ 1 ln-e � [�@J- �� city iN Lot Size <br /> Job Address - <br /> t. yLA <br /> >C Address 4— '0• hone e'3 <br /> Owner_s,Name'." <br /> 63 Phone .L1_7—2 1 <br /> Contractor's Name License No. a ,_ _ _ _9.L1_7-_L1 <br /> n N <br /> NEW WELL ❑ WELL REPLACEMENT LlDESTRUCTION ❑ S <br /> i <br /> TYPE OF WELL/PUMP: ; <br /> "IPUMP INSTALLATION ❑ SY TEM EPA f OTHER ❑'" <br /> DISTANCE T 0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ti t E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom—Q—Manteca_.„„ -»Dia• of Well Excavation - _ Dia.*of Well Casing ,. <br /> NTracy Type of Casing `�� Specifications 0) <br /> ❑ Domestic/Private El 0thierl Pack +r�`Delta -Depth of GraSeal � "j TYpof Grout <br /> El Public <br /> ❑ Irrigation ___Xpprox. Depth ❑ Eastern Surface Seal Installed by: J <br /> Repair Work Done ElType of.Pumpr H.P. State Work Done C <br /> Well Destruction ❑ Well Diameter ` ealing Material Stop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑k=REPAIR/ADDITION DESTRUCTION ❑ aNailabpelwth5n 200 feet.) if public sewer is <br /> F <br /> Installation will serve: ResiderI Commercial_j,} Other <br /> Number of living units: Number of be rooms—' <br /> r" Water table depth- <br /> Character of soil to a depth of 3 feet: - �, t <br /> '""r Capacityft� tNofCompartments ' <br /> SEPTIC TANK ❑ Type/Mfg # <br /> PKG. TREATMENT PLT. ❑ 'Method of Disposal`^�` <br /> Distance to nearest: WellFoundationProperty Line <br /> LEACHING LINE No. & Length of lines "- r -- Total length/size <br /> r ..� .. <br /> FILTER BED ❑ Distance to nearest: Well Founds ions r P operfy Line <br /> Number <br /> SEEPAGE <br /> i SEEPAGE PITS ❑ Depth L Size �� <br /> i. SUMPS Distance' nearest: Wei� ff oundation — Property Line <br /> DISPOSAL PONDS ❑ <br /> r I hereby certify that I have prepared this application anti that the work wiH;be,done in accordance with San Joaquin county ordinances, state laws, and <br /> r 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 /> oomt <br /> employ any person in such manner as'"to bee•subject fo-workman's'C:b perisation laws of California."Contractors hiring or sub-contracting signature <br /> l 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 is ' ; <br /> 4 The applicant mu II for all r uired inspections. Complete-drawing n reverse side•---�-- <br /> Sined Title: _�� — Date: Q I <br /> g <br /> f FOR DEPARTMENT USE ONLY <br /> $ Application Accepted by Data <br /> Pit or Grout Inspection by !V [)ate Final Inspection by Date <br /> ` Additional Comments: .I <br /> ❑ Stk 466-6781 ❑ Lodi 38.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 { <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 I AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0." <br /> INFO CASH <br /> + EH 13-24(REV.10183) <br /> EH 1426 'y <br />