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R'I APPLICATION FOR PERMIT �' <br /> cJ� g <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA r1 <br /> Telephone (209) 466-6781 -4 <br /> [ -4 <br /> r <br /> �I I 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 wellipump and the Rules and Regulations of the.San Joaquin <br /> Local Health District. I <br /> City "Vwl Lot Size PM <br /> Job Address. � <br /> 7� � Phone <br /> Owner's Nam (�3-31 a <br /> �Q Address Nd e • � y <br /> ll <br /> Contractor <br /> — srre.s Address iL���' £ [• License No.3 q Phone <br /> TYPE OF WAltPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER_LINES.- DISPOSAL FLD. PROP. LINE <br /> PITS/SUMPS <br /> _ FOUNDATION r AGRICULTURE WELL OT <br /> INTENDER USE TYPE OF WELL PROBLEWARI=A� C_ONSTR SPECIFICATIONS . <br /> ` ��— of Well Excavation Dia. of Well Casing <br /> El Industrial El Open Bottom ❑ Manteca <br /> ❑ Domestic'/Private ❑ Gravel Pack ❑ Tracy A'�Type of Casing Specifications <br /> Ii ❑ Other to 'Depth,of,Grout Seal Type of Grout <br /> FI I Public <br /> I I Irrigation, _Approx. De t I Eastern Suriace SSeal installed by <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. ca <br /> '1 Sealing Material atop 50'1 <br /> Well Destruction ❑ Well Diameter <br /> Q ! Depth I Filler Material 16eiow 501 <br /> a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia :REPAIR/ADDITION l I OCSTRUCTION (Nosbetic system <br /> m permitted if public sewer isava (� <br /> eet.I <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:' � <br /> Water table depth <br />' SEPTIC TANK El Type/Mfg v i Capacity s <br /> No. Compartment <br /> t , Method of Disposal <br /> PKG. TREATMENT PLT. 01. t , <br /> li Distance to nearest: Well foIndatidn Property Line <br /> LEACHING LINE ❑ No. &�Length of lines ,� Total length/size <br /> ' 1 Property Line ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation`_._. k <br /> SEEPAGE PITS I 1 Depth I Size Number <br /> SUMPS ❑ Distance'to nearest:. Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared thi's 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 /> Nome 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'work.7iWs 6ompensafion jaws of California. Contractor s hien 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 must call for all required - spec ions. Complete drawing on reverse side. <br /> Signed k Title: Date: <br /> 2y2 i [. �^ DEPARTMENT USE ONLY <br /> �aAp/p`tfiJca on cc3pted by • Date Area <br /> Pit or Grout inspection by <br /> t Date Final Inspection by Date <br /> il .4th*► s '), 7f_ (? `7 ogle <br /> r Additional Comments: e_ <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ M nteca 823-7104 LJ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> o >, llrc <br /> € E CK RECEIVED BY DATE PERMIT'NO. <br /> FE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> (NFO2 <br /> 00 <br /> *.EH t3-241HEV.1/R51 ) - <br /> j EH 14-2e CJ <br />