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SA <br /> � � PPLICATION FOR PERMIT TJ <br /> ® E� AN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Sr? 1988 Telephone (209) 466-6781 <br /> tyYp,L "VkU"MIT EXPIRES 'I'YEAR FROM DATE ISSUED <br /> E% 1�RM J1,ZER\J10ES (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 Couhty Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the Sen Joaquin <br /> Local Health District. 1.1 <br /> o ., <br /> Job Address City I:VL-- L�olt Size / PM <br /> Owner's Name ` ddress �1 1�7� � � �" ^�" - Phone Lo ^ Q <br /> Contractor <br /> �',P ? �" '`""' Add . '""�(_. License No/6 � /373 Phone `a <br /> -Address - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ti WELL REPLACEMENT_❑ DESTRUCTION ❑ \ <br /> PUMP INSTALLATION❑ ti, ft SYSTEM REPAIR ❑ OTHER ❑ \ <br /> DISTANCE TO NEAREST: SEPTIC TANK ,.SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WO Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Ll Other i. F1 Delta Depth of Grout Seal Type of Grout <br /> i 9 <br /> I 1 Irrigation —.Approxi Depth I I Eastern ace S,'I Installed by <br /> Repair Work Done a Type of Pumps H.P. � �� � State Work Done <br /> Well Destruction ❑ Well Diameter Sealing`Materia! (top,'50') <br /> Depth ; Filler-Material (Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fa REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other t" k <br /> Number of living units: Number of bedr_otms _ .. ' ff <br /> Character of soil to a depth of 3 feet: # '"`;' k"'� ' : Water table depth <br /> --SEPTIC TANK " ❑ Type/Mfg Capacity ! No. Compartments <br /> �., r I' i <br /> PKG. TREATMENT PLT..'Cl ;.";' " Method of Disposal <br /> FounBation"'""*""�"""�—PFoparty-Line--��^`- <br /> i + <br /> a LEACHING LINE ❑ No. & Length of lines i Total length/size <br /> 'FILTER BED ❑ Distance to nearest: Well Foundation, Property Line <br /> N <br /> SEEPAGE PITS 1 I Depth t Size Number <br /> � t E <br /> SUMPS 0 Distance to nearest: Well Foundation 1. Property Line # <br /> DISPOSAL_ PONDS ❑ <br /> 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 i <br /> rules and regulations of the San Joaquin Local Health Diltrict. '`4'1 ` sha1!1 <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 ll not <br /> employ any person in such manner as to become subject to workman's compensation laws„of-California.” Contractor's hiring or subcontracting 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." t { <br /> The applica , ust II for 11 requi dd inspections. Completedrawing on reverse side. <br /> Signed X `" d title: {f Date: Z,� 00 <br /> FOR PARTiU1ENT USE ONLY <br /> Application Accepted by ; Date Area a <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: f <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. Bax 2009, Stk., CA 95201 <br /> f <br /> FEE AMOUNT DUEl AM UNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a.EH13-24 IREV.1/rt 51 <br /> EH 14-2s <br />