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y I <br /> APPLICATION FOR PERMIT _ [) <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete.in Triplicate) <br /> fi <br /> Application is heieby 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 �) r-� 14 City e ` Lot Size PM <br /> Owner's Name 49!a 'r C Q.� s�,r 4 cuf_Address' ✓� F' Phone <br /> Contractor !Il�C� _j ] ._l �(�Address w?.I!.�C 1 Z i4_G License No Phone r a !! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR W OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �} <br /> + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —Y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open,13ottomti­1 ❑ Mantecaa Dia-.,,of-Well Excavation Dia. of Well Casing <br /> f <br /> Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications <br /> – 0 Public-.- * ,_ �_ 0 Others— ❑ Delta Depfh of Grout Seal Type of'Grout <br /> ❑ Irrigation 7_ —_Approx. Depth ❑'`Eastern SurfaceSeal Installed by <br /> Repair Work Done Type,of Pump H.P. State Work Done <br /> Well Destruction LJ Well Diameter Sealing Material f'top 501 I <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION l]' DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg -Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,', Method of Disposal <br /> Distance to nearest: ` Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> - <br /> FILTER BED ❑. Distance to nearest: Well Foundation °Property Line <br /> SEEPAGE PITS ❑ Depth - Size Number, <br /> SUMPS ❑ .Distance to nearest: Wel! Foundation J Property Line <br /> DISPOSAL PONDS ❑ - --^- <br /> I hereby certify that I have prepared this application and that the work will be doneJn.accordance-with-San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> t 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 as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the fallowing: "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." a _ , <br /> �. The applica st call for a!I required inspection . Comp drawing on reverse side. <br /> Signed X Title: f P . ; Date:l �d 4 <br /> s FOR DEPARTMENT USE-ONLY--^-- "f----�-- o <br /> a <br /> Application Accepted by Date /U Area <br /> Pit or Grout Inspectio Date- Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi, 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK <br /> INFO AM�OUNT+DUE A N7 REMITTED CASH RECEIVED BY DATE PERMITNO, <br /> -♦ EH13-24(REV.I/k5) <br /> EH 14-26 <br />