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�' •tiwti"�\. . 5 <br /> i <br /> _ APPLICATIDN FOR PERMIT <br /> Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 ci <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rutes-and Regulations of the San Joaquin <br /> Local Health District. ' <br /> i <br /> Job Address City Lat Size PM <br /> r�} <br /> Owner's Name t f 1 frL Z�-[,Lkbawi TAddress e0 /c,5-5 ,,. (� P hone <br /> I x l- <br /> Contra�cfof Address C B22dd License No: Q=crL Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTA.LLA;;T11I-O� NV�1 SYSTr�M�1REFAIR ❑ j�OT�HE�R ❑ f , <br /> DISTANCE TO NEAREST: SEPTIC TANK. LOW SEWER LINES . !(SCD -- DISPOSAL FLDyry.f�LQ,['M1 PROP. LINE L {Lf <br /> FOUNDATION� AGRICULTURE WELL OTHER WELL►�fLJ_h�. PITS/SUMPS wk)e— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing <br /> 1-Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing c2�Ele k Specifications <br /> ('1 Public F] Other o- FI Delta Depth of Grout Seal Type of Grout <br /> 1 Irrigation —_Approx. De th I 1 Easi r Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. a .,, State Work Done <br /> — <br /> Well Destruction ❑ Well Diameter'll Ser aling Material (top 50') <br /> Depth Filler Material lBelow 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION i.I DESTRUCTION i I (No septic system permitted if public sewer 1s <br /> available within 200 feet.) <br /> Installation will serve: Residence_: Commercial -_ Other <br /> Number of living units: Number of bedrooms <br /> i <br /> Character of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1` <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to'nearest: Well Foundation Property Line <br /> f ' .! <br /> LEACHING LINE 1; ❑ No'& Length -f-lines Total length/size <br /> FILTER BED ---El �'Distancefto nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth r`4 size Number <br /> SUMPS ❑ Distance to ne.1.0 : 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-Ds%trict. a <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 compehsation 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 lawsof Califo <br /> A Jy <br /> The applic nt st call for all required ' dtions-�Comple drawing o4 everse-side. <br /> Signed Date: t <br /> F DEPARTMENT USE ONLY <br /> N + <br /> Application Accepted by 9 Date Area f' <br /> Pit or Grout Inspe*tion by l� Date / Fina! 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO GASH IT <br /> RECEIVED BY DATE PERM "IVO.EH 1 3-24 <br /> EH 14-26 r [IREV.tin51 �o J <br /> t <br />