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` a APPLICATION FOR PERMIT / <br /> l SAN JOAQUIN LOCAL HEALTH { ��' <br /> DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA�� r r <br /> Telephone (209) 466-67816P <br /> `7, <br /> i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED � <br /> r (Complete in Triplicate) �� sv%R ,GAS <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woFkVbereln 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 /> Job Address N/ D T!2 City Lot Size <br /> PM <br /> Owner's Name t Address G k Phone `�qa <br /> Contraclor�,g�� Address 8 <br /> - License No. S- la 2-- / - <br /> Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION lSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:'SEPTIC TANK 7 ---SEWER LINES DISPOSAL'FLD. PROP. LINE <br /> FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br />�L-7 Industrial —� --w­❑-Open-Bottom 4 ❑ Mafriteca----- Dia.-of-Well-Exc:j'v—ation Dia of'INeI! Casing-W' '� <br /> 1)110omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> CI Public C1 Other ❑ Delta Depth of Grout Seal <br /> Type of Grout _ <br /> I i Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. . % State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material /top 501 <br /> Depth Filler Material (Below 50'I ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is { <br /> 1 <br /> Installation will serve: Residence=� Commercial._ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:;I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg} Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' 1 <br /> Method of Disposal 3 <br /> Distance to <br /> tinearest: Well Foundation Property Line i <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance toynearest: Well Foundation + Property Line <br /> i� <br /> SEEPAGE PITS I I Depth I Size <br /> Number .__. <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ sI <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--' .—,4 <br /> 'rules and regulations of tthe San Joaquin Local Heath'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, 1 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 the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to,workman's compensa- ri <br /> tion laws of California." <br /> The applicant must c r requirod inspections. Complete drawing on revs se side. <br /> Signed X <br /> Title: <br /> Date: <br /> 69Z — _FOR DEPARTMENT USE ONLY <br /> dd ai <br /> Application Accepted by R i Date Q <br /> as <br /> Pit or Grout Ins <br /> pectian by Date Final.Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 " <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> ` FEE AMOUNT DUE AMOUNT REMITTED 14 <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO.' <br /> + EH 13-24{REV.i /_v, sy�7 ,f7 pl 16 { <br /> EH 14-26 (/(J <br />