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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 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 Na-549 for sewage or No. 1862 for welt/pump and the Ruies aCd egulAtjRn f a n Joaquin <br /> Loco <br /> I-Hea <br /> Ith District. 1!� <br /> r !' 4N City Lot Size PM <br /> �. <br /> Job Address"i <br /> i i 3 <br /> I +" Address 1 t 3` � r Phone <br /> Owner's Name <br /> t 2Z <br /> + r kr Phone <br /> Contract dress License No. <br /> TYPE OF WELLIPUMP NEW WELL ❑. WELL REPLACEMENT-,LJ DESTRUCTION ❑ <br /> =°..... <br /> PUMP INSTALLATION ❑ i+ "- ,SYSTEM REPAIR ❑ r' + �._,+ OTHER ❑ <br />' �. SEWER LINES DISPOSACFLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK f <br /> -"' - FOUNDATION' AGRICULTURE WELL OTH>R WELL- 'PIT$ISUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial L1 Open Bottom Manteca . Dia. of Well Excavation Dia. of Well Casing <br /> + ❑ Domestic/Private ❑ Gravel Pack ❑ TFacy N-" Type of Casing Specifications <br /> F7 Public �n Other n Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation _.-Approx. Depth t I Eastern ! I Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump . H•P State Work Done <br /> 1'�Well Destrudtion ❑ Welf.Diameter +a Sealing Material (top 501 <br /> tiler Material (Below <br /> .,.�— <br /> �',�4.TTYPE OF SEPTIC WORK-,-NEW INS ION-Wf�REPA•IR AD ITION IV DESTRUCTION I ].(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Instaltatiori wil! serve: Re i en ce .Commercial ther r <br /> 1 <br /> ^' Number'of.living-units: Number o rooms /00 � <br /> Character of soil to-a depth of 3 feet: y Water table depth <br /> 4, '' '4^ Type/M� f'Capacity No. Compartments <br /> t SEPTIC TANKx;�° ^� 4. f Method of Disposal <br /> 0637 TREATMENT PLT. ❑ w r p <br /> i + d. Foundations Property Line <br /> Distance to nearest: - Well � � s <br /> �_ — <br /> ACHING LINE 17-1No. & Length+ of lines - Totat-lengthlsize <br /> LE <br /> f \dELYU BSD. p-- ❑ TDistance to nearest:•.'r ;VU t1 Foundation Property Line <br /> Number <br /> i SEEPAGE PATS I -"Depth Size <br /> SUMPS Ll Distance to nearest:' Weil > � Fou dation �t Cf -.Property Line S t� <br /> 1 x <br /> DISPOSAL P<S ❑ `- <br /> L.tiereby4certifyFthxt I have'prepared this application and that the work-will be-do <br /> ne in accordance with San Joaquin county ordinances, state laws, and <br /> I rules and regulations of the San Joaquin Local Health District. -fit <br /> Home owner or ficl nsed agent's`sigr:ture,certifies the following: "I certify that in the performance of the work for which this permit s 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 csub-contracting signature <br /> cerci- '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 /> "A <br /> tion laws of California." <br /> }7The`applicant-mus II forfell req ins ctians. Complete drawing on verse side <br /> Signed X <br /> L' Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date f Final Inspection by <br /> . a <br /> Additional Comments: <br /> ❑ Silk 466-6761 El Lodi 369 3621 ❑ Manteca 823-7-104 El Tracy 835-6385 <br /> Applicant - Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> 4 • <br /> i INFO AMOUNT bUE AMOUNT REMITTED �K RECEIVED BY DATE jPERMIT'NO, <br /> + EH 13-24(REY:l/nn) —� <br /> I EH 14-2e <br />