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L <br /> APPLICATION FOR PERMIT <br /> l <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781. <br /> PERMIT EXPIRES TYEAR 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. <br /> Job Address 917(a2 (21 <br /> POAJ City RIPOAJ Lot Size I�Ct►'� PM <br /> Owner's Name �r�V i Address ��Me Phone <br /> Contractor • ' e Address � �i�'� ��e License No.�y J13 Phone <br /> TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑= ,: OTHER ❑. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ., PROPS LINE 1 <br /> N FOUNDATION AGRICULTURE-WELL" OTHER WELL "' PITStSUMPS <br /> .INT! . DIED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS <br /> ❑ Industrial'*, El,Open�Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> e t <br /> ` ❑ Domestic/Private ❑'Gravel.Pack ❑ Tracy Type of Casing Specifications <br /> f"1 Public f Other F] Delta Depth of Grout Seal Type of Grout <br /> i I I Irrigation r °Approx. Depth I I Eastern Surface-Seal Installed by _ <br /> Repair &ork Done ❑ �Type of Pump H.P. State Work Done <br /> P a . <br /> Well Destruction ❑�, Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 r <br /> F TYPE OF SEPTIC WORK:ro 'NEW INSTALLATION I t REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will serve: Residence= Comrltercial_ Other <br /> Number of living units: Number f bLedrooll � <br /> 'kjCharai ter of soil to a depth of 3 feet s �N� _ Wafer table depth <br /> SEPT1CaTANK El Type/Mfg- =^" -� f- PillCapacity �� � No. Compartments ` <br /> PKG._TREATMENT PLT. ❑ I13 i ++ a Method of'`Disposal <br /> Distancb,to nearest: yr Well F �O Foundation b Property Line <br /> 1~,_:, <br /> LEACHING LINE sNo�&_Le 9;h,pf_lines a Total length/size <br /> FILTER BED ❑ Distance to nearest: Well t 20 t Foundation lV Property Line r <br /> SEEPAGE PITS 1 I; Depth -fly,? .ryr Size Number <br /> SUMPS Ll Distance to„nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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:�l 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 pe oormance 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.applicantfor all quired ins ctions. Complete drawing on reverse side. <br /> 4 .Signed X--",=.� Title: Date: I 8 <br />{ f DEPARTMENT USE ONLY <br /> . �Application Accept)dby Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 1466-6781' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> A.ppiicant - Retum,tll copies.ta_Enviro mental -P.ermit4Services 1601_E.-Hazelton.Ave:;-P.O.-Box-2o09r5tk:,�CA-95201»-- <br /> EEE AMOUNT DUE AMOUNT-REMITTED.# ' RECEIVED BY DATE PERMIT'NO. <br /> INFO * CASH <br /> ♦ EH 13-241REV,1/"n) t� 1 z ! _.p � <br /> EH 14-28 C) ^ ,, �1I an Jr JJ�5 <br />