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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f�aLD �G/z <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA t <br /> I <br /> Telephone (209) 466-6781 fnta�' <br /> PERMIT 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> I <br /> Local Health District. <br /> s <br /> Job Address 3b 1 �, d1r- &3.4 ` City Lot Size PM <br /> Owner's Name :> Address 129 W, JK n Phone <br /> Contractor kI Address '77qN1, �IS LPhone 3 3 ` -9 1-3o <br /> TYPE OF WELL/PUMP: ;1 NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> s PUMP INSTALLATION F1 - SYSTEM REPAIR.❑. ,:-_ _,.-,,...OTHER,❑ <br /> DISTANCE-TO NEAREST: SEPTIC,TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION -,.AGRICULTURE WELL OTHER WELL ' PITS/SUMPS i <br /> rINTENDED USE TYPE OF WELL PROBLEMAREATZGONSTRUCTIO SPECIFICATI <br /> ❑ Industrial Open Bottom ❑ Manteca •`—"Dia. of Well ExcavationDia. of Well Casing <br /> { S-a% It <br /> ❑ Domestic/Private ❑ Gravel Pack C1Tracy t Type of Gesjr <br /> ng_.___---� 2ge-9 Specifications �l <br /> M Public ❑ Other ❑ Delta �'4 Depth of Grout-Sea[ .f Type of Grout <br /> rrigation —.Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. r•�''�=" State Work Done— �! <br /> Well Destruction. ❑ Well Diameter ,SeaIiFg_Maf6riALltop"50'1`"`" <br /> t} <br /> N, fDepth 'Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION I 1 s`REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> • t` } available within 200 feet.i - <br /> f Insialfation will serZ—,"l esidence_ Corrimercra!_ Other <br /> N mbe {r of living units: v° Number,of bedrooms , <br /> Character of soil to a depth of 3 fee 1. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.JFREATMENT PLT. ❑ Method of Disposal <br /> Distance nearest: Well Foundation Property Line <br /> ® s`fF <br /> LEACHING LINE ❑ No. & Length'of lines Total length/size . <br /> FILTER BED ❑ Distance to no Well Foundation Property Line <br /> L SEEPAGE PITS. _ I I Depth ':� Size Number <br /> F SUMPS ,. - "�""""0''Distance to est: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepare 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 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 a% to become subject-to Wdrk- ah's compensation-laws of California." Contractolr's hiring or sub-contracting signature <br /> certifi'6s 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 Californ' <br /> Thesapplicant must all r all re uireti spec(�amplele ng onreverse side. <br /> jSigned X e: Date: <br /> s <br /> FOR DEPARTMENT USE ONLY ry <br /> Application Accepted by _ :r. Date ! Area <br /> Pit or Grout Inspection by Date Final Inspection by D to <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 635-6385 <br /> Applicant - Return all copies to: EnvironritentalHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE.` PERMIT NO. <br /> �.EH 13-24 IREV,I/n sl ��`� <br /> tt EH 14-28 - 9-sr— <br /> �` � <br />