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~` APPLICATION FOR PERMIT <br /> , 4 <br /> c SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE.,,STOCKTON, CA <br /> " Telephone {209} 466-6781 <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 Herein described. T application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump_and the Rules and Regulations of the an Joaquin <br /> Local Health District. <br /> Job Address / ! ; r,.J�'.' <br /> city�� Lot-Size PM <br /> Owner's Name V 1 Ste) I IN .J.61-1 IA� Add14r"� � - � Phone � d� <br /> Contractor W A L1AL.k��PJ dress 2 50 UJ C-L icense No. d Phone <br /> ' ­4­jc v°E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f <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 j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT(ON$ T1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing �. <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy rType-of Casing Y r Specifications t <br /> ❑ Public ❑ Other ❑ Delta <br /> LDepth of Grout Seal Type of Grout r <br /> i�•lirigatio'n JApprox..Depth,,; ❑,Eastern.,. —4 Surface Seal Installed by t �\ <br /> ,'Repair Work DoneOType of Pump ° H.P.. _ State Work Done <br /> Well Destruction 1 ❑j' ',Weil Diameter Sealing Material (top 50'1 ,ter <br /> r -t i't 1 14 Depth Filler'Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION TRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.l t <br /> E Installation will serve: Resi ence— Commercial_ -Other , <br /> s <br /> "'Number of living units: Number of NBArooms <br /> Character of soil to a depth.of 3 feet: f _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments : <br /> PKG. TREATMENT PLT. F� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line t <br /> LEACHING LINE ❑ ei'"& Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> I <br /> S <br /> SEEPAGE PITS ❑ Depth Size Number <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 /> 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 /> ploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> ce the following: "1 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 California." <br /> The applican ust call 4or Il re fired pact s. C plate drawing on reverse side. <br /> . , r <br /> 5i X )L Date: 2 <br /> _# FO/DEPARTMENT USE ONLY <br /> Ma <br /> Application Accepted by Date Area <br /> Ulr <br /> Pit or Grout Inspection by ' Date Final Inspection by Date I <br /> 'r <br /> Additional Comments: <br /> ❑ Stk 466-6701 ❑ Lodi 369-3621 L1 Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> + EH14-24(REV.I/ sl <br /> EH 14-28 <br />