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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> F. Telephone (209) 466-6781 <br /> 4 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 Flutes and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address _4 ! [-_utpii-f h� City W,bl Lot Size PM <br /> C , <br /> 4 Owner's Name Address ' � �/lj�/ 29 _ <br /> Phone <br /> ems/ <br /> Contractor ! -t 1 Address 1License 1 No. <br /> b ��r 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. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation j Dia. of Well Casing <br /> F`❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C ' <br /> F f'l Public Ll Other ❑ Delta Depth of Grout Seal <br /> I l P Type of Grout.' <br /> I i Irrigation —_..Approx. Depth I I Eastern -- F <br /> i P. �Suriace Seal Installed by <br /> Repair Wark Done fJ Type of Pump :H.P.." State Work Done_ ' ? <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 �� y <br /> Depth ,Filler Motorial (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION STRUCTION I.] (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r Installation will serve: ..Res ence�'VCommerciai Other r r f {� <br /> t Number of living units: Number of b r oms <br /> Character of soil to a depth df 3 feet:l I [� W---- - Water table depth <br /> ,SEPTIC TANK Off.-Type/Mfg <br /> Capacity— No.:Compartments r <br /> PKG. TREATMENT PLT. ❑ 1 ` <br /> ��/"�/' Method of Disp Sal <br /> Distance to nearest: well, Foundation,1(�._" Property Line <br /> � � F <br /> 'LEACHING LINE LR- 116. & Length of lines "V e Total length/size <br /> FILTER BED ❑ Distance to'nearest: Well; Foundation -Property,Line i. <br /> #SEEPAGE PITS t li- dbpth —Size, Norpber f , <br /> SUMPS Ll Distance toynearest: Well: Foundation`` ! <br /> "' � 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 f <br /> rules and regulations of the San Joaquin-Local Health Dis;trict:...- <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 laws of California." Contractor's hiring or sub-contracting signature <br /> certifies <br /> eonifiesthe f fCaffomga,' certify that in the performance of the work for which this pe"4iit-is issued,-I shall.employ`persons subject to workman's compensa- 1 <br /> 1 The applic st for I req ed i PNctiqns. Complete drawing on <br /> Worse sid ! <br /> Signed a -`;=T r Da_nAte:, � <br /> F RTMENT USE,ONLY E <br /> Application-Accepted by TA6A a <br /> ,'� <br /> Date Area _ <br /> Pr or Grout Inspection by ,��r��ii 'ae3 1f7 <br /> d`�— - Final Inspection by <br /> Additional Corilments: f ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 6237104 ❑ Tracy- 835-6385 . f <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 '""' 1 <br /> INFO CASH �.RECEIVED BY DATE PERMIT'NO. <br /> ♦.EH 13-21(REV,IiKs) <br /> EH 11-28 <br />