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r ofl ` <br /> i` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> 1601 E. HAZELTON 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 <br /> I 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 L City-5k Y�— Lot Size pM 'PM/!1 1811% <br /> Owner's Name Y?5�� _f gddres �' ' _ - /� _ Phone <br /> Contractor's Name <br /> Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> d AN — <br /> i - FOUNDATION- _ _AGRICUL=TURE- VEL-L-----TpT}{ER:wE-LL-.- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S <br /> ❑ Industrial I \ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private \. 0.Gravel Pack ❑ Tracy Type of Casing S <br /> pecifications <br /> ❑ Public ❑ Other "if El Delta Depth of Grout Seal Type of Grout <br /> '' A \ `1 <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by v" <br /> f Repair Work Dane ❑ Type of p <br /> H.P. State Work Done <br /> Pum <br /> Well Destruction ❑ WeII Diameter '` Sealing-Material-(top_50. <br /> Depth 1T=iller Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ' REPAIR/ADDITION ❑ DESTRUCTION .d (No septic system permitted if public sewer is <br /> L available within 200 feet.) <br /> Installation will serve: Re 'dente_commercial Other <br /> Number of living units: . Number of bedrooms * s „( <br /> Character of soil to a depth of 3 feet: . L ^- Water table depth (4 <br /> SEPTIC TANK ❑ Type/Mfg`I C y Capacity i �� C3 No. Compartments <br /> PKG. TREATMENT PLT. ❑ `,,"�F� Method of Disposal <br /> Distance to nearest: well 10 Foundation a 0 Property Line I' <br /> LEACHING LINE f�i­No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance toynearest: Well Foundation L Property Line <br /> f SEEPAGE PITS ].­Depth -5Size ? " 1- ` Number <br /> SUMPS ❑ Distance toknearest: Well > -Foundation- 9 0 .Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be clone in accordance with San,Joaquin county ordinances, state laws, and <br /> rules and regulations of the.San`Joaquin Local.Health.District.—j <br /> Home owner or-licensed agent's signaturerce'rtifies 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 the following: "I certify that in the performance of the work for which this permit is issued,f shall employ`persons subject to workman's compensa- <br /> .on laws of California." I <br /> The a must call f all r ire i pact a. mplete drawing on verse std . <br /> Signa rtle: 5 '.�.•. <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by f� Date Area—� ID- <br /> Pit or Grout inspection by I K Date l �� Final Inspection Date v ' o�J <br /> r Additional Comments: 4 <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-362111 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK x RECEIVED BY DATE` PERMWNO. <br /> r { `CASH,,,h. <br /> + EH 1324{pEy, 101831 +--h {� -0 C, <br /> EH 1426 II I l(J l �CJ <br />