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.-F <br /> `:���000-✓'-r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. ,HAZEITON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE_ISSUED_,, t , <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 Joacuin-County Ordinance"No.543 for sewage or•No..1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District-.4.,F r .�PxslDpD t5-) <br /> � <br /> Z� .//l5- <br /> Job Address / _ City lot Size ' PM <br /> u Owner's Name _-• Address - <br /> . - t __._. Phone <br /> Contractor's Name ja, License No. phone r O <br /> ,TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑- DESTRUCTION -0 <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 i I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> .❑ Industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private E3_Gravel Pack .11 Tracy Type of Casing —Sp4 <br /> ecifications j <br /> PPublic ❑ "Other ❑ Delta Depth of Grout Seal y Type of Grout f <br /> ❑ Irrigation €" Approx. Depth ❑ Eastern Surface Seal Installed_by_! <br /> Repair Work Done ` ❑ Type of Pump H.P. 'State Work Done .4'' ' - :-1 <br /> 'Well.Destruction ❑ Well Diameter I Sealing Material (top <br /> f <br /> •Depth f Filler Material (Belo } ,4. I. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION; DESTRUCTION ❑ (No septic system permitted if.publ'rc seeder is " <br /> available within 200 feet.) n <br /> Installation will serve: Res' enc - Commercial_ OtherJ. <br /> Number of living units: Number of be ooms_ ' IK t ," � �} ! <br /> ' Character of soil to a depth of 3 feet: <br /> p - ��� _-Water table depth <br /> SEPTIC TANK ❑ -Type/Mfg _ _ ! Capacity . No. Compartments <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> } u .a Distance to nearest: Well Foundation Property Line <br /> ;I ; 3 <br /> -. <br /> LEACHING LINE I No. & Length of lines Total length/size _ <br /> FILTER BED ❑ ;Diitahce to nearest: Well Foundation Property-Cine <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ' �..: Distance to nearest: Well Foundationg. Property Line t <br /> L' <br /> DISPOSAL PONDS" <br /> -f hereby certify that f have prepared this application , that the work will 1e done in accordance with San Joaquin cou.ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Healtti District: <br /> Home owner or licensed agent's signature certifies the.following:-'J,certify that in the,performance of the work for which this permit is issued, I shall not <br /> 'employ any person in such manner as to,became 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 persohs subject to workman's compensa- <br /> tion laws of California."-* <br /> z The applicant st for all rinspections. Com to drawing on,! rse side. <br /> = (�'L <br /> Signed '� Title: <br /> Date: <br /> i <br /> FO Vt DEPARTMENTUSEONLY fl <br /> Application Accepted by. Date — C>�� Area <br /> ' y P <br /> Pit or Grout Inspection byDate Final Inspection by ALL Date <br /> Additional Comments: ' <br /> °i❑ Stk 466-6781 _ ❑ Lodi 369-3621 ❑'Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE"; AMOUNT REMITTED CASH RECEIVEQ BY DATE PERMIT N0." <br /> r - <br /> 0,0 <br /> f es+EH 1&241REV. <br /> EH 1428 g II V v <br />