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APPLICATION FOR PERMIT 3`� l <br /> SAN JO <br /> AQUIN LOCAL'HEALTH DISTRICT ; <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6* APS <br /> PERMIT EXPIRES 1,YEAR FRO WDATE ISSUED ' t'' "3 <br /> a <br /> ENV-iRQJT%6ENTAL HEALTH <br /> (Corriplete'in Triplica#e1 ' p ',.F iT/SERVICES <br /> .� t : ;� ,. .• iia :.ar ,;..~ •b „�, ,,.,. ... ., f , <br /> Application isherebymade 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 Ryles and Regulations of the San Joaquin <br /> Local Health District: <br /> z •t �, , ' C ty/ _'` " l 'Lot Size . +. . PM J l <br /> Job Address <br /> Q A f7 ??- / -c /X �.-M Phone f <br /> Owner's Name '--�"`�'� �" Address C� <br /> Contractor <br /> 3X-��C� 1! Address (° 4 License No�C� � Phone�/T G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANKS. SEWER LINEDISPOSAL FL17. PROP. LINE <br /> 6 <br /> FOUNDATION AGRICULTURE WELL ^-� W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> "omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Ll Other ❑ Delta <br /> -Depth of Grout Seal Type of Grout I <br /> ❑ Irrigation ---Approx. Dep1h ❑ Eastern Surface Seal Installed by y� <br /> Repair Work Done 74/ Type'of Pump H.P. - State Work Done/ <br /> Well Destruction ❑: Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material [Below 50') <br /> l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avlailabpe1within 20D feet.) if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: -- .Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,, -- - _• """' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines R Total len.9 <br /> 1 <br /> }FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE-P_1TS—..,...,•. D—, Depth-== = -Size Number <br /> I <br /> SUMPS ❑ Distance to nearest. Well Foundation Property Line — <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 the San Joaquin Local Health District. <br /> k Home owner or licensed agent's signature certifies the following: '9 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 applica must call for all re uired inspect, ns. Complete drawing on reverse side. <br /> I- <br /> tie-` <br /> FOR <br /> Date: <br /> 'Sign. �} <br /> FOR DEPARTMENT USE ONLY r <br /> Dates Area r <br /> 1k "Application Accepted by <br /> I Date Final Inspection by DateS <br /> Pit or Grout Inspectio <br /> jAdditional Comments: <br /> i ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services-16011 E.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK# RECEIVED BY,. DATE PERMIT`N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH Q�7 t <br /> + EH 1&24lREV.i/957 w 14—S4 U f + 113 . <br /> EH 11426 <br />