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-� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> J ' 1601 E. HAZ E•,.t ON.AVE., STOCKTON, CA kp C <br /> Telephone (209) 466-6781 Ec � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRUME`"TAL HEALTH <br /> I M fjfffSERV <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 appljCES <br /> sc §n 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 /> Job Address ®� 'r_v„ r �b1�J-f r , ST - Cit Lot Size PQM <br /> Owner's Name Address �r 0sIV, `' � Phone <br /> r <br /> CorstractorI Address Z. License No. Phone <br /> TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 4k-' OTHER ❑ <br /> DISTANCE TO NEAREST: SEP4IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL , PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s+� <br /> ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 4Type of�Casing Specifications <br /> i"I Public ❑ Other Cl Delta Depth ofGrout_Seal , ._._„Type of.Grout j" i <br /> I I Irrigation � WYE Approx. ,ptp- .I��I East/grrnn Surface Seal Installed by <br /> Repair Work Done Type'':of Pump / /Xjw1 State Work Done 29 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> } <br /> &`pth+ Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW, INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION i I (No septic system permitted if publiclsewor is <br /> available within 200-feet.) � <br /> Installation will serve: ResidenceCommercial Other <br /> / l <br /> Number of living units: Num 69i.pf,bed,00ms ; <br /> Character of soil to a deptK of i3 feet: Water table depth <br /> SEPTIC TANK M,,Type/Mfg i Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑1 Method oftDisposai f <br /> t <br /> istance to nearest: Well Foundation Property Line <br /> LEACHING LINT= ❑ No.I& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t • <br /> t f <br /> t <br /> SEEPAGE PITS I I Depsh Size — Number <br /> SUMPS ❑ Distance to nearest: Well Foundation— Property Line , <br /> DISPOS?L PONDS ❑ _-- <br /> I hereby certify that I have prepared this application and that-theWork w111'b Sdone-in accordance with San Joaquin county ordinances,state laws, and <br /> a <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> Homeowner or I' a 's signature certifies 1he fallowing: "I certify that in the performance of the work for which this permit is i;s_16ed, I shall not <br /> employ any p on in such man eras to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> certifies the Ilowing: "I certify at in the or nc ork for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws o California. iw <br /> The applic nt must r requ ompl to drawing on raver f w= <br /> Signed { Title: s Date: <br /> FOR qPARTMENT USE ONLY <br /> Q � <br /> Application Accepted by r Date /'� �y Are <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: End ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMMOUN�T RUE AMOUNT REMITTED CCK 0 RECEIVED 13Y DATE PERMIT-NO. <br /> EH 14-2e Cf <br />