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I <br /> APPLICATION FOR PERMIT <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1641 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> t (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 Rules and Regulations of the San Joaquin <br /> Local Health District. t <br /> Job Address <br /> City '11% i'O Lot Size PM <br /> i <br /> Owner's Name M c 11 EA61 Address c Phone <br /> �' - . Phone_ <br /> Contractor � Address u License No.aS:FJ&' <br /> F STY-IVASY.- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> k _ -.PUMP INSTALLATION.LJ,. - r _ --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 /> Dia. of Well Casing <br /> ❑ Industrial � fl Open Bottom' ❑ Manteca Dia. of Wel! Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f_1 Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 <br /> 11 Irrigation _.-Approx. Depth i I Eastern Surface Seal Installed by - <br /> 'r, Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done— <br /> Well Destruction © Wel! Diameter Sealing Material (top 501 4 <br /> Depth Filler Material (Below 501 -- <br /> C TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is <br /> / available within 200 feet.) -� <br /> Installation will serve: Residence✓ Commercial—3 Other <br /> Number of living units: ___L_ Number of bedrooms <br /> Character of soil to a dept of-3 feet:— - c _ •Water table-depth <br /> SEPTIC TANK r Type/Mfg: P1.- f —[.pnr d c �� Capacity ) it _ No. Compartments <br /> PKG. TREATMENT PLT. L) � Method of Disposal <br /> k �,I <br /> 4 Distance to nearest: W70 <br /> e11 Foundation�lL� Property Line �1 t1 r <br /> length/size <br /> len Q <br /> LEACHING LINE �No.'& Length of lines d Total� g <br /> ! FILTER BED ❑ Distance to nearest: Well } Foundation_ Property Line tA4r� <br /> SEEPAGE PITS I 1 Depth size Number <br /> SUMPS ' LlDistance to nearest:•-�- -Well Foundation PropertyZine <br /> DISPOSAL PONDS fl <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 Diltrict. <br /> t 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 the following: 'Tcertify 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.:,." <br /> The applicant.must call -all <br /> alLquired inspections. Complete drawing an reverse side.:,Signed X " � - Title: <br /> Date: - <br /> y <br /> FGJ911E)EPARJAENT USE ONLY <br /> ,/ �� <br /> Application Accepted by Date/ a <br /> Pit or Grout Inspection by Date Final Inspection by Datp�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 fl 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 FEECK <br /> INFO <br /> j,AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY J/BATE PERMIT'NO. <br /> a.EH 13-24(REV. <br /> �Q <br /> F EH 14-26 <br />