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APPLICATION FOR PERMIT !` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1PERMIT 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 application is <br /> made in compliance with San Joaquin County Ordinance No.549 for'sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I Ii4eC <br /> ° a _ PM <br /> Job Address r � ��"!5- ' =~.City Lot Size <br /> Phone <br /> Owner's Name : � 4 R 4� Address ga L / <br /> (� ense No. Phone <br /> Contractor Address Lic <br /> I <br /> TYPE:OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 <br /> PUMP INSTALLATION ❑ '. SYSTEM REPAIR C1 OTHER ❑ <br /> DISTANCE TO NEAR IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS ` 1 <br /> INTENDED USE $ TYPE OF WELL PROS CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca D1 . II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private i; ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V\' <br /> ❑ Public <br /> j y i ❑ Other ❑ Delta- Depth of Grout Seal a of Grout <br /> ❑ Irrigat9on # �4pprox.'Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 3 Type of Pump H.P. State Work pone <br /> Well Destruction l• Well Diameter Sealing Material {top 501 t <br /> '• Depth Filler Material (Below 501 <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence Commercial— Other <br /> Number of living units: 1 Number of bedrooms <br /> k Water table depth <br /> Character of soil to a depth of 3 feet:i <br /> SEPT�C TANK _ ❑ Type/Mfg -Capacity—.2---old) --No.-Compartments'" <br /> PKG.$TREATMENT-PLT.OY Method of Disposal <br /> Distance to nearest: well, <br /> Fofindation Property Line <br /> LEACHING LINE No. & Length of lines Total lengthlsize <br /> F: ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation' �r Property Line_ !Q <br /> 1 <br /> SEEPAGE PITS iiDepth i Size "' Number i <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ . . . <br /> I hereby certify that I have'prepared this apOlication acid that the Work will be done in accordance with San Joaquin-county ordinances, state laws�and <br /> 1 rules and regulations of the San,Joaquin Local Health District. + t" <br /> I Horne owner or licensed agent's signs the following: 'l certify that in the performance ermitis issuid,l l shall not <br /> employ any person-in such manner as to become subject to workman's"compensation faws.of Cof-the work for whlch this.palifornia."6ontractors hiring or sub contracting signature <br /> cert'if'ies 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 /> G tion laws of California." 3 f -•-^� <br /> The applicant must call for all equired inspections.Complete drawind on reverse side. <br /> Date, <br /> Signed A. [ ":Title: >:- x a ,- <br /> f � ' <br /> FOR DEPARTMENT USt ONLY-_, <br /> r <br /> Date 6 Area <br /> 1 Application Accepted by <br /> Pit or"Grout Inspection by Date Final Inspection by Date- <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy r 635 6385 <br /> { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y � <br /> e CK:- �_ —F <br /> - <br /> y FEE., •„„- __(-j If�,�,.,- „�.. :,_ r- <br /> ' INFO AMOUNT DUE A�VIOl7M11T'I'lE7WITTED`�" CASH R RECEIVED BYDATE PERMIT'NO.�� <br /> ` + EH 13-24 CREW.5/'s 51 <br /> EH 14.28 <br />