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- APPLICATION FOR PERMIT L_ <br /> r. SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 4 to ly. -6400 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> {Complete in Triplicate) r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructand/or install the work herein described, This application made H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 18fi2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. � pp Icarion is <br /> pain <br /> Job Address _ <br /> ' Lot Size LCity �kl �rJr1 7�jj�� � � �– PM <br /> Owner's Name �ciri�r_ <br />� `�, Address <br /> Phone <br /> Contractor r (/, � ' <br /> Address r'U� �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License fYo. Phone <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK i/SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL --` PROP' LINE <br /> TYPE OF I <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> ID industrial Open Bottom WELL PROBLEM ACTION SPECIFICATIONS <br /> ❑ —� <br /> REA CONSTRU <br /> f-1 Domestic/Private ❑ Manteca Dia. of Well Excavation " <br /> LJ Pack ❑ Tracy Dia. of Well Casing <br /> f'1 Public ❑ Other Type of Casing r <br /> 1 C7 Delta Depth of Grout Sea! Specifications <br /> I i Irrigation <br /> --_Approx. Depth I 1 Eastern Type of Grout <br /> Repair Work Done 0 Surface Seal Installed by ` <br />. Type of Pump H.P.Well Destruction ❑ Welf Diameter State Work Done <br /> Sealing Material (top 50') _ <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION 1 No septic system permitted if public sewer is <br /> Installation will serve. Residence Commercial_ Other��� vailable wilhin 200 feet.) <br /> Number of living units: Number of bedrooms - nny_ <br /> �� E ! ,V,ft A4 d0A1.tEi.3-r <br /> Character of soil to a depth of 3 fear. <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity— No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line� •� <br /> LEACHING LINE ❑ No. & Length of fines <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth <br /> SIZE Number <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS F) Foundation Property Line <br /> rl <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 /> 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: "I certify that in the performance of the work for which this permit is issued, I shall employ r <br /> tion laws of California." p y persons subject to workman's compensa- <br /> tion <br /> appliteb <br /> for all requir in ions. Complete drawing on rev rse side. <br /> Signed X r� <br /> Title: <br /> yt Date: <br /> FOR DEPARTMENT USE ONL 51iMrN�+C <br /> Applicatio ��� f <br /> Date Area <br /> Pit or Grout Inspection by Datef� �7 <br /> Final Inspection by Date `� y <br /> Additional Comments: <br /> ❑ Stk 486-6781 ❑ Loch 369-3621 } ❑ Manteca 823-7104 $ <br /> 5-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Haza ton Tracy A3e., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED RECEIVED BY <br /> E <br /> CASH DATE PERMIT�NO. <br /> + EH 1324tREV.linsl <br /> EH 14-26 U _ <br />