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APPLICATION FOR PERMIT 1 <br /> k; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601. E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in;Triplicate) r <br /> 1 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 /> ,% 1, <br /> Job Address <br /> s`t"" "' City Lot Size PM <br /> -' Owner's Name iY Address _ v Phone '4 <br /> Contractor Ilr_i(' Address_P�_� �C " ter License No. r11. .Phone <br /> i s <br /> TYPE OF WELLlPUMP: NEW WELL .0 WELL REPLACEMENT' �� DESTRUCTION L1.�-w..,;. PUMP-•INSTALLATION-❑ ----• S -0REPAIA Q'-""—OTHER`❑"'"'""1" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -� <br /> s <br /> f: FOUNDATION AGRICULTURE,WELLY - OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll industrial El O,Pen Bottom, -_0 Manteca,: Da�of Well_Excavation. -- k Dia. of We Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> s <br /> ❑ Public 1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout J) <br /> ElIrrigation --J-Apprax. Depth ❑ Eastern Surface Se?l Installed by I <br /> Repair Work Done ❑ Type of Pump H,P. - State Work Done t <br /> Well Destruction 0 `Well Diameter Sealing'1g­M6te�r-ialr(topW') <br /> Depth Filler Material (Below 501. l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El DESTRUCTION 1-1INo septic system permitted if public sewer is <br /> 14.,,- /.�... ,. --- �--available within 200 feet.) <br /> Installation will serve: R idents t�/-Commercial__Other. <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of'31eet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Disitn Method of DiTysal <br /> I anceao�near`e�t: Well Foundation Property Line <br /> LEACHING;:LINE W No.&gth of lines( �fi T�tal length size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> j SEEPAGE PITS ❑ -Depth ` —f '"" *Size Number <br /> O <br /> SUMPS. e,,,4.,-..t, Distance to nearest: `t Well Foundation Property Line <br /> +- 1` .u "" <br /> DISPOSALPONDS O As <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 ceitifies 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 thej'following: "I certify that in the per formancerf the work for which this permit is issued,1 shall employ persons subject to workman's campensa- <br /> tion laws of California."' I t - <br /> The.applieant must call for all, squired inspections. Complete drawing on reverse side. <br /> Signed XX 1 114,11W2 ; Title: Date: <br /> VJ <br /> t r OR DEPARTMENT USE ONLY <br /> Application,Accepted by Date Area <br /> e <br /> Pit or Grout Inspection by Date Final Inspection by L;2 Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ,,❑ Manteca 823-7]04 ❑ Tracy 8354385 I <br /> t Applicant-Aeturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE- AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> ,INFO CASH <br /> + EH 13-24 EV '���^��� '-'^..""�' ....- -,-.....- --n-:�.r- -� �c�.,..,. �•ice+-�+.. <br /> EH 14.28 ! C� O - "!7 <br />