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5-1 <br /> r - APPLICATION FOR PERMIT ` <br /> � N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,vSTOCKTON, CA ' <br /> Telephone 12091'466-6* <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED1rt7u► <br /> . (Complete in Triplicate) ,'t's <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 /> Local Health District: �� <br /> Job Address 63.� City Lot Size Ad k lea PM <br /> Owner's NameUOL,`rCA�=61M OX r` Address C7 03. r.s-- sl '-"'tRPhone <br /> 5- s ti.Lp �•., (^ <br /> I <br /> Contractor � Address License No. ('hone <br /> TYPE OF WELL/PUMP: (NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f\ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing } <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy k Type of Casing Specifications ` <br /> li ❑ Public ❑ Other ❑ Delta j Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth._.C-Eastern E Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> { Well Destruction ❑ Well Diameter f Sealing Material (top 501 <br /> l Depth +,I: i Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION' INo septic system permitted if public sewer is <br /> ( vailable;within 200 feet.) <br /> Installation will serve: Residence�— Commercial_ Other} <br /> Number of living units: Number of bedrooms ; <br /> Character of soil to aept of 3 feet: - Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PL . ❑ 1. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 11 <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest`. Well Foundation—.Property Line <br /> ,l <br /> i _ _ <br /> SEEPAGE PITS ❑- Depthr1 Size Number <br /> SUMPS ❑ Distance-to nearest: Well - Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have preparedithis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> g 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 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 I <br /> The applicant must call for all required inspections. <br /> .Complete drawing on reverse side. <br /> XSigned X - ��� �z/� Title: � _� Date: 1,119 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final Inspection by - Date <br /> f Additional Comments: r� k1--X Z,,? �2 - <br /> F ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 8355-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Y <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> ♦ EH 13-24(REV.i/tt 51 - dl B� fS <br /> / �­np7kzl2gA <br /> EH 13-24 <br />