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F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELTON`AVE,, STOCKTON, CA <br /> -Teleplibrr `i 2091 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM:DATE ISSUEDr <br /> � f:. <br /> (Compleie'in Triplicate? '` <br /> 0! <br /> Application is hereby made to the San Joaquin Local Health District for 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. 'r. <br /> Job Address '`� ' � `''" t µmi Y' CityF; Lot Size 3 !.-, PM <br /> i S <br /> Owner's Name -_Address e ` �`l G Phone <br /> .. <br /> .sTfr— , <br /> Contractor ;1�►�titi Address V X"r' _License No:%�237Phone <br /> TYPE OF WELL/PUMP: iVfW.WELL © WELL <br /> EPLACEMENT ❑ DESTRUCTION ❑, <br /> PUMP INST-Al SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERILINES DISPOSAL FLD. I PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM`AREA CONSTRUCTION SPECIFICATIONS a <br /> ❑ Industrial ❑ Open Bottom ❑'Wnteca- Dia. of Well Excavation. iDia. of Well Casing <br /> LJ Domestic/Private LJ Gravel Pack{ �q Tracyv Type of Casing 4Specifications <br /> ❑ Public ❑ Other ❑`Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation.1 — /'<�Approx. Depths El Eastern urface Seal Installed by <br /> Repair Work,,DO e�"�Y>T.ype,of Pump 3 9 H,P, State Work Done <br /> Well Destruction © Well Diamete f'-- Sealing Material (top 501 <br /> Depth r•1 Filler Material (Below 50') € <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION 1-1DESTRUCTION C1 (No septic system permitted if public sewer is <br /> available within:200 feet.) <br /> Installation will serve: Resi a�e—I Commercial— "Other E <br /> Number of living units: Number of bedrooms' . <br /> Character of soil to a de'pth_of 3 feet: I Water table depth <br /> SEPTIC TANK fO .Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT--[]. } Method of Disposal y �_ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE/ ❑ -No. & Length of lines Total length/size ' <br /> FILTER.BED/ ❑ Distance to nearest: Well Foundation PropertyLine <br /> SEEPAGE PITS © Depth ; Sizey Number <br /> SUMPS ElDistance to nearest: Well +.Foundation Property Line- <br /> DISPOSAL PONDS E) <br /> Ilkie Ay 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 /> 4.,rules and re ulations of the San Joaquin Local Health District. J# <br /> Ho nor or Ice agent's signature certifies the following: "i certify that in,the performance of the work for whichithis permit is issued, I shall not <br /> e loy any person in su manner as to became sub' t to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> { tic rtifies the followin :"I ify that in th perform ce f the work f r which this permit is issued,I shall employ persons subject to workman's compensa 1 <br /> til n laws of Californ b . ` <br /> f `T applicant mus or all re i� i s . n o plete awing on.re side <br /> Signe r Title: Date: <br /> FOR DEPAR ENT USE ONLY 3 ��f <br /> Application Accepted by (O�/ �,= -� *--� ' �--.~ - ^-=---- flate�1!/ '� J <br /> ,,,;-w•��. �•"'"----� � Area <br /> r ' <br /> Pit or Grout Inspection'by'"'"' W �' I Dateh% w ,ti Via. Final Inspection by __� -Oate �t�—�8—t3S <br /> Additional Comments: " .. <br /> k' <br /> ❑ Stk' 466-6781 =_Godi 369-3ei'01 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 } <br /> Applicant - Return all,.copiekto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk� CA 95201 <br /> CK <br /> INFO AMOUNT DUE, AMOUNT REMITTED CASH RECEIVED BY DATE. PERMIT'NO. <br /> + EH13-24(REV.1/ss) r <br /> EH 1426 <br />