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E , <br /> I <br /> APPLICATION FOR PERMIT <br /> 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) . { <br /> Application is hereby made to the San Joaquin Local HealthDistrict 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. II <br /> .s- 4/ Lot 'iiz PM <br /> Jab Address {� �� Ci <br /> 5 (,•+- l ` ' Phone <br /> Owner's Nam - ;` Address <br /> " '�o r Phone ' -7ids— <br /> Contra <br /> ct Address License No. � <br /> I <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION' ❑ t SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION L, AGRICULTURE WELL OTHER WELL_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom i ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grav6i'Pack ❑ Tracy (Type of Casing"-'`F _ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout <br /> ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by A w. <br /> Repair Work Done ❑ Type lof•:rump H.P. State Work Dolle <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') Ln <br /> Depth --1 -r I Filler I ' (Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ REPAI ADDITIO 2—DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ` available within 200 feet.) <br /> Installation will serve: Residence � Commercial_ Oth r "_�_ ��,y„�• <br /> Number of living units: ___Z_ Number of be' ooms• , �f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ``` y Capacity No. Compartments <br /> I PKG. TREATMENT PLT. F] - Method of,Disposal <br /> Distance to nearest: Well Foundation - Property Line <br /> I LEACHING LINE Uk--"No. & Length of lines 0 Total length/;ii,', x <br /> FILTER BED ❑ Distance to'nearest:' Welf- '�70f­ Foundation Property Line' fy_, <br /> SEEPAGE PITS ❑ Depth " Size --d 3 ' ''Number <br /> SUMPS ❑ Distance to nearest: }Well = r� ',Foundation z Property Line <br /> DISPOSAL PONDS ❑ 4 ` <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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any persomin such manner as to.become'subject to workman's compensation laws of California.",Contractor's hiring or sub-contracting signature <br /> 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 California." <br /> The applicant.1 ust call for; required inspections. Complete-drawing on reverse ide. l a <br /> Signed Title Date: <br /> FOR-•OEP T USE ON Y \ <br /> Application Accepted by Date` Area Z _ <br /> Pit or.Grout.lnspection by... <br /> ' /Date -Final Inspection by-- - - --- "'Date — <br /> - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ElLodi 369-3621 E] Manteca 823-7104•, d• ❑ Tracy $36385 f`. <br /> k AQplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boli 20.09, Stk., CA 95201 <br /> u <br /> FEE AMOUNT DUE AMOUNT REMITTED CA <br /> K# RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-24(REV.i/a5) <br /> EH 14-26 S S <br />