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APPLICATION.FOR PERMIT k <br /> o <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone '{209) 466-6* <br /> PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED <br /> -(Complete in Triplicate} <br /> f 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 t <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:' T'' <br /> { Job Address l- I.Cit x 4 <br /> Y. Lot-Size PM <br /> , .- � � <br /> Owner's NameAddress �­Phonef <br /> / a <br /> Contractr e&t ' Address �C7 ([ 3z��z �� a,g ��.�' <br /> License No. Phone <br /> q T E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .❑ i <br /> 41 f } <br /> DISTANCE TO NEA7� EPTIC TANK 4901 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOU AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS �-- <br /> d ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation <br /> Dia.of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack" ❑ Tracy Type o S ` <br /> pecifcations <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sea Type of Grout f <br /> ❑ Irrigation J4pprox.'Depth ❑ Eastern Surface Seal Installed by <br /> i Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done_ <br /> Well Destruction ❑ Wel! Diameter`.: Sealing Material (top 501 <br /> Depth t: <br /> Filler Material (Below•50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is h <br /> f6` available within 200 feeiJ, <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number;of bed ooms R y <br /> Character of soil to a depth of 3 feet: Water table depth- <br /> SEPTIC TANK ❑ Type/Mfg. apacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' <br /> Method of Disposal 999 <br /> Distance to` nearest: t Well Foundation Property Line <br /> " LEACHING LINE [R' No✓�& g Ith of lines C) �( <br /> r{ Total length/size <br /> FILTER BED ❑ Dist a to nearest: Well��_ Foundation~8 �Pro e r <br /> p rty-L•ine--_-c�-^" <br /> { SEEPAGL+PITS , 1 ❑ Depth S Size r X _ �x Number�� --- <br /> S t 0 �Disfance to nearest: Well P r ( �' <br /> � �� Foundation �� I" - Property Line <br /> DI PONDS 11if ❑ 1 r <br /> I h rtify thanl have preparpid this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rul d gulatior*of the San Joaquin Local Health District: . <br /> Ho w r or licensed.agent's signature certifies the following:,"I.certify thatln,the,performance of-the work for which this p mit is issued, I shall not <br /> e � -person•4n such manner as-to become subject-to work`man's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ce r h following:"1 certify that in the performarice of the work for whicFi this permit is issued,I shall employ persons subject to workman's compensa- <br /> 4i do s California." # <br /> �i Th applic n ust_caIIIIse r1 ed_mspectioris.1 Complete drawing on reverse side. <br /> SignedData,,{ <br /> Title: <br /> ri FOR DEPARTMENT USE NLY- ' <br /> J� <br /> .J Application Accepted by Date - <br /> Area <br /> IPit or Grout Inspection by Date Final Inspection by <br /> ?Additional Comments: - <br /> i❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> k <br /> ;Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE G AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> + EH:13-24(REV.1/e5) <br /> EH'4.28 <br /> s. <br />