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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 1601 E. HAZE LTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ! <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ri, , <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �.; .. _. . ..¢a�N Ohl-iia.-,-11" <br /> f ? <br /> Job Address <br /> / /J/ i City Lot Size PM <br /> y .. , <br /> .Owner's Name /. '` xUzy Address ;Phone <br /> _Rap a _ _ _ _ __ -1 <br /> _ `-�w <br /> Contractor ��� Address `� /�KS� �� License No. Jed-1,f347Phone <br /> OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ <br /> DISTANCE TO NEARE TIC TANK SEWER LINES (DISPOSAL FLD. PROP. LINE <br /> -- <br /> FOUNDA AGRICULTURE VELL OTHER WELL PITS/SUMPS <br /> INLENDED USE TYPE OF WELL PR AREA CO'§STRUCTION:SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of,Well E16vatwn -" Dia. of Well Casing ! <br /> s� <br /> O Domestic�/,P� vate ' ❑ Gravel Pack ❑ Tracy Type of~ �_ Specifications <br /> ❑ Pubic *; ,0e ❑ Other ❑ Delta Depth of Grout Seal,+ Type of Grout <br /> ❑ Irrig do r�. --Approx. Depth ❑ Eastern Surface Seal Inptallid by <br /> Repair Work Done, El Type of Pump H.P. / '{ ��,State Work'Done1 <br /> Well Destruction �,,❑ Well Diameter Sealing Materia/ll liop 50') <br /> l (•9eI <br /> epth Filler Materialow 50') <br /> TYPE OF SEPTIC WORK:,►,NEW INSTALLATION ❑ REPAIR/ADDITIO� L DESTRUCTION ❑ (No septic"system permitted if public sewer is W <br /> .._. .-•-- � -�- available within 200 feet.) Op <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number o be rooms 3 ! <br /> Char cter of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity— <br /> /No. Compartments <br /> PKG. T�EATMENT PLT' ❑ '' � (s�/ � Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> i a �. <br /> LEACHING LINE f ' ❑—No. & Length of lines w Mei Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> R` <br /> SEEPAGE PITS Z?- Depth ?�6T Size Number <br /> SIJ•IVGPS I ❑ Distance to nearest: Well'. 4M Foundation 7S Property'Line <br /> 11 f� <br /> %iDISPO PONDS i ❑ � f <br /> I hereby ffy tftrrha.ve prepared this application and that they work will be done in accordance with San Joaquin county ordinances, state laws, and 1 <br /> rules and regulations of the San Joaquin Local Health!District. � t, <br /> Home owner or licensed agent's signature/c rtifies the;following: 'I c 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 be6ome subject to workman Wmpensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in theyperformance 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 f I required irLspe i ns. Complete drawing on reverse side. f r <br /> f <br /> Signed Title: Date: <br /> OR DEPARTMENT USE ONLY ✓ ` <br /> Application Accepted by, % Date ,L Area ©2 <br /> I � <br /> Pit or Grout Inspection by i Date J— Final Inspection by Date <br /> Additional Comments: <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. Box 2009, Stk., CA 95201 <br /> FEE CIK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> +EH 13-24(REV.1/a5) - c 1 <br /> ` <br /> EH 14-28 �Q� .fl , �� O 7_In <br />