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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 'Telepho'ne {209} 466-6781 •� SIO�D <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 hereiri'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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address + .� t City-���"� Lot Size„ PM <br /> Owner's Name.i u_ Em2 S Address - Phone <br /> I Address, <br /> _ { j <br /> Contractor;'- Ep— �6Ljk`�,O Address 3-5b cense No. •- (5L/9)--Phone ; <br /> TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMEN "❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 1 CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca ( Dia. of Well Excavation Dia. of Wel{ Casing; <br /> . ❑ Domestic/Piivate' ❑ Gravel `Pack t 0 Tracy J{Type of Casing I <br /> Specifications Y ? <br /> ❑ Public ❑ Other ❑ Delta Depth-of-Grout-Seal­--_4___________ Type of Grout f <br /> i ❑ Irrigation __-Approx. Depths ❑ Eastein} Surface Seal Installed by <br /> Repair Work Done ❑'<-Type of Pump - —H.P. � � �� '� State Work Done <br /> Well Destruction _O._-.-Well-Diam. r• ---�-*i "� eDSealing-Material�tiip 50'1 <br /> ... - <br /> 3 g Depth '� `" `killIer Material-f Below,509 I i d <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION EPAIR%ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sew_6r±is <br /> i ..___ available within 200 feet.) . <br /> Installation will serve: Re idence L Commercial_ her µ t } <br /> Number of living units. Number be ooms I <br /> Character of sail.to a depth of 3 feet f _A Water table depth <br /> r ' <br /> SEPTIC TANK L_-Type/Mfg Capacity 1 b On No. Compartments <br /> E PKG. TREATMEN PLT. ❑ r Method of Disposal } <br /> j pp Distance <br /> to no t:. Well '"' ;Foundation Property Line I p <br /> LEACHING LINE �fVo. & Lei gth of lines 5 Total length/size <br /> FILTER BED ❑ -Distance'to nearest: Well Foundation Property Line <br /> } ! t <br /> ! _ <br /> SEEPAGE PITS ; IiYGepth Size CRNumber <br /> SUMPS I ❑ Distance(to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS! ❑ t ! r <br /> I hereby certify that I have prepared thi application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and.regulations4of the San Joaqu'n Local Health District. i �; <br /> rr- <br /> Hom'e_owner�or licensed agent's signet re certifies the following: "!certify that in the performance of the work for which this permit rs issued, I shall not <br /> employ any perso ",such manner as to become subject to workman's compensation laws of California." Contractor';s hiring or sub-contracting signature <br /> certifies the follo ..Ing: certify that in t ie performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion f California.". <br /> e applica' t ; atcallfor II qui d ns ions. Complete drawing o verse <br /> Signe Title: ��: Date: <br /> I-- 4 <br /> FOR DEPARTMENT USE ONLY I <br /> Application Accepted by, - Data I <br /> y� Area 2- <br /> ` <br /> k>i � C > j <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> of V <br /> i # <br /> Additional Comments:'', i "lam °+ r .-�S� <br /> k 466-fi781 ❑ Lodi 369-3621` '❑ Manteca 823-7104 Trac 8355-6385 <br /> App scant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO j AMOUNT DUE AK 591MOUNT REMITTED C K �RyECCEIVE BY DATE# PERMIT NO. <br /> + EH 13-24 f REV.)9 5) !�} L.�{•�'� 5005 O• &G-0. <br /> EH 14-26 l FF CC„JJ <br />