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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ fl <br /> 1601 E. HAZEL I ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 �� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMIENTAL HEALTH <br /> t (Complete in Triplicate) PERMIT/SERVICES, <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 1,?gA /I 4L' �• City i 0 Lot Size PM <br /> j - 1 777— <br /> Owner's Name illuf ��� Address Phor, <br /> Contractor u Address Z5 (` icense No. c2k A3 Phone <br /> TYPE OF WELL/PUMP: v NEW WE" ❑ . WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. JIM PROP. LINE <br /> FOUNDATION, AGRICULTURE WELL.. OTHER WELL 3Q PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing gi <br /> ~ R ye, Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �5� ' _ Tye of Grou <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> (11� Lqe,5 Depth_h Filler Material (Below 501 <br /> l/I TYPE OF SEPTIC ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />} <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. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest....r,� Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS�"O­ —" <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 <br /> 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 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t call for all re uired)' pections. Complete drawing on rev s' p <br /> Signed Title: r Date: o <br /> FOR DEPARTMENT US ONLY <br /> Application Accepted by epr�r� tDa�teO< - "' Area Q <br /> r flnss�/I?,j i - i .r�t.tr —Date i1— 7 <br /> Pit or Grout lection b Date pection b <br /> Additional Cortfm'eh 1 <br /> ❑ Stk 466-5781 ❑ L. 1 369-3621 ❑ Manteca 7104 ❑Tracy 8355-6M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED O SH RECEIVED BY DATE PERMIT`10. <br /> INFO <br /> + EH 13-24(REV.1/85) & 46ELI� <br /> EH 14-28 <br /> v <br />