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APPLICATION FOR PERMIT ly <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT R ���VD <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ; <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tr►^ (Complete in Triplicate) <br /> ` Sion is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d �l�� <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the,Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> /1 Y'1P �r U /` ] II OV City &SCA3`�,t Size'— PM <br /> fz <br /> 1 _ Phone <br /> Owner's Name ZZAtiTess S� <br /> i <br /> j 1rxf.).� 6� License No. l Phone Uy' <br /> Contractor -� ��/ Address_, <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 CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ,,,.: <br /> f] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 171 Gr'avel Pack-"t ❑ Tracy Type of Casing Specifications <br /> ❑Public-�• --- .- -� -L]-Other ��: ^�—� ---❑-Delta--• �— — _Depth of Grout Seal �--. -— <br /> .Type ofGrout^ -�-- <br /> ❑ Irrigation ---Approx. Depth Surface Seal Installed by P <br /> 1 <br /> i Repair Work Done X Type of Pump H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material 06p 501 <br /> Depth Filler Material ISeiow 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iavailableticsystem <br /> temfeitted if public sewer is <br /> e <br /> Installation will serve: Residence, Commercial Other <br /> l � <br />€ Number of living units: Number of bedrooms + <br /> Character of soil to a depth of 3 feet: Water table depth tA <br /> .� <br /> SEPTIC TANK ❑ Type/Mfg Capacity -No. Compartments s ° <br /> F-1Property <br /> of Disposal <br /> PKG. TREATMENT PLT. <br /> r } <br /> Property Line <br /> ? '� � � r � - k Distance to nearest: Well Foundation <br /> hIa e <br /> I LEACHING L1NE�' "''I'❑ No. &Length of lines Total length/siz <br /> - ; <br /> FILTER BED ❑ Distance to nearest: Well' �- Foundation Property Line f <br /> SEEPAGE PITS ❑ Depth '- _ _Size Number <br /> i <br /> SUMPS El Distance to nearest: Well! FoundAation Property Line S <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 <br /> rules and,regulations of theanoaq <br /> SJuin Lgcal-Health District. <br /> Homo owner or licensed'agent's signature•ceriifies 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,"I shall employ persons subject to workman's compensa- <br /> tion laws of.California.,' ' _> <br /> The applicant_ call for SII requi ed' i s. Complete drawing on re erse side. �^+ <br /> Signed -+, Title: Date: T� <br /> s } FOR DEPARTMENT USE ONLY I <br /> } FL Z <br /> ! Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection b <br /> Date Final Inspection by DateY <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 /> FTEE7 AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT"N0. <br /> INFO CASH <br /> + EH 1324 iREV,1/e 57 �� �� --�`r �1' "� <br /> EH 14-26 <br />