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_ /41, ' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 5 <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. t <br /> Job Address O City Lot Size 4�v x�0 PM <br /> { ; _ L10 _ 3v� <br /> Owner's Name0010 dress F 47 4 2—o Phone <br /> ' i /0�- <br /> .,._ Contractor Address -� License No.M3 Phone-- —li-� <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> s1 - PUMP INSTALLA ION ❑ SYSTEM REP OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK-. SEWER LINES DISPOSAL FLO. PROP. LINE , <br /> FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS ) <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS j <br /> ❑ Industrial ❑ Open Bottom eco Dia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> 4 ❑ Public ❑ Other ❑ to Depth of Grout Seal Type of Grout <br /> f ❑ Irrigotibn �pprox epth ❑ East n Surface Seal Installed by <br /> Repair Work Done-., ❑ Type of mp P. State Work Done <br /> ` Well Destruction ❑ We iameter . ling Material itop.50') <br /> e Depth Fill Material (Below.50'.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A DITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer i f. <br /> available within 200 feet.) <br /> .; Installation will serve: Residence_ Commercial Other`" <br /> Number of living units: Number of bedrooms <br /> s f <br /> Character of soil to a depth of 3 feet: n._ _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity U —No. Compartments <br /> h PKG. TREATMENT PLT. ❑ :. Method of Disposal <br /> f- <br /> Distance to nearest: Well Foundation Property Line L l <br /> I ` <br /> ti <br /> LEACHING LINE ❑ No. & Length of lines 0 <br /> r7Total length/size r- t <br /> FILTER BED ❑ Distance to nearest: Well?0 Foundation—2 Property Property Line I <br /> SEEPAGE PITS ❑ Depth _Z Size 47y Number f T # <br /> SUMPS -0❑ Distance to nearest: Well f- Foundation0 Property Line <br /> DISPOSAL PONDS <br /> Li a���`5 S a-A­4' (54— Lc u <br /> r <br /> I 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. 'I <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 taws,of Cafiifornia;"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 Iavh of California." <br /> The applican ust call for II require inspections. Complete drawing on reverse side. ` <br /> Signed n Title: (��[ Date: ( — <br /> .L y FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` Area ` <br /> Pit r Grout Inspection by Al Date,/—R 7Finai Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 } ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> x <br /> Fi y <br /> t 4' <br /> INFO AMOUNT DUE AMOUNT REMITTED s CASHCKO RECEIVED BY DATE PERMITNO. <br /> + EH 1324(REV.t/a s) A ' <br /> ,I i <br /> EH 14-28 �' x ( S <br />