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r <br /> I 4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephorle (209) 466-6781 <br /> ii <br /> �! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 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. l <br /> i <br /> Job Address �� I '! [ f7�17 City Lot Size PM <br /> d� <br /> Owner's Name Address r lr Phone <br /> Contractor l ,e _rite-oss 4=105 Address r License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t <br /> k PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK L Q SEWER LINES DISPOSAL FLD. PROP. LINE 1!L' <br /> FOUNDATION -- — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY E OF WELL PROBLEM AREA CONST RUI;TION`SPECIFICATIONS <br /> ❑ IndustrialOpen Bottom C1Manteca Dia. of'Well Excavation "� Dia. of Well Casing <br /> Nebomestic/Private ❑♦Gravel Pack ❑ Tracy Type of Casing Specifications n <br /> M Public n,Other F Delta Depth of GroutrSeal /7V)-"�--_ _ hype of <br /> I I Irrigation "'" = Q'}1'pp�oiT 'Dia�pt�h'• ,—�tLLEastern- <br /> ____S <br /> Repair <br /> Seahlnstalled by (�lC/� <br /> Repair Work:Done ❑ Type of Pump- 4H.P. ? f�� State Work Done <br /> k y <br /> Well Destruction - 1❑ .Well Diameter Y'' Sealing Material (top 501 <br /> DeptMiler Material-iBelow 5011 <br /> ` <br /> TVIU OF SEPtIC WORK: NSW'INSTALLA•TION l 1 1'9EPAWA_r DITION f.1 "DESTRUCTION I I (No septic stem permitted if <br /> l i•. _.,-It , p Y p p`ubiic�sE er is <br /> `.__�.. available within 200 feet.h <br /> Installation will se. Residence.-__,_CommerciaC' 01/her <br /> Number of living units: ber of bedrooms f <br /> Character of sail to a depth oLZ <br /> f 3 feet: r Water table depth <br /> SEPTIC TANK ❑ iType/Mfg Ca <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,; Method of Disposal ; <br /> 1. 7 <br /> ` Distance to nearest: Wel Foun Property Line <br /> I { <br /> t <br /> LEACHING LINE ❑ ONo. & of lines Total ie size 1 <br /> FILTER BED ❑ stance to nearest: Well Foundation Property t r <br /> SEEPAGE PIT l I 40apth Size Number <br /> SUMPS Cl ,:Distance to nearest: Well Foundation Property Line <br /> D OSAL PONDS ❑ II <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, starts laws, andE <br /> rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agents 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 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- <br /> tion laws of California." I! <br /> Theapplicant us all for alt ire fired ins ctions. Complete drawing on reverse side, �} b <br /> Signed Title: Date: IU ! I( <br /> I+ <br /> iFOR DEPARTMENT USE ONLY /{, <br /> Application Accepted by Date !V Area <br /> Pito Gr t Inspection by Date Final Inspection bye`/ ci Data <br /> Additions! Comments: <br /> !1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 ` <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEINFO AMOi1NT DUE AMQUNT REMITTED CASFI RECEIVED BY DATE PERMIT'MO. <br /> ' � t <br /> a.EH 1241ttEV-1/X51 pu f <br /> EH 14-4-2A <br />