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APPLICATION FOR PERMIT �� <br /> I� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601`E..HAZELTON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 t h <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED it <br /> 4 (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.This application 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 /> -� r <br /> Job Address _ City of Size a <br /> PM ' <br /> f n_ <br /> .Owner's Nam �/ � 6LI +IC, <br /> I Address ��.A57 V�i.cj phone c? <br /> Contractor Address j . <br /> C License No. Phone <br /> TYPE OF WELL/PUMP: i�' NEW WELL ❑ WELL,REPLACEMENT`❑ It DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 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 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ° <br /> 9 Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seat <br /> �I p Type of Grout i <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material (top 50') <br /> 04 <br /> ;I. <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 1(No septic system permitted if public sewer is ! <br /> I�. "available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other t <br /> Number of living units: �R Number of bedrooms <br /> F <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ElType /Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> IL <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ D`istance to nearest: Well Foundation Property Line <br /> a <br /> SEEPAGE PITS �❑ Depth Size F. I <br /> r <br /> SUMPS ��-�` � � � �i' - '•_ Number � <br /> ❑ Distance to nearest:' Well <br /> IIIIpp Foundation Property Line <br /> DISPOSAL PONDS ❑ Bl <br /> I hereby certify that f have prepared this application and that the work will <br /> rules and regulations of the Sari`Joaquin Local Health District. ws, anbe done in accordance with San Joaquin county ordinances, state lad <br /> j <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 t <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." III <br /> The applic ust cal or all required i ctions, plate drawing on reverse side. <br /> X Signed C, Title: ®cl.)f AZ1 lcl- �-1 r`c,Q <br /> �.J 1 <br /> l Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Lf <br /> Date Area <br /> Pit or Grout Inspection -rt <br /> Date Final Inspection by }, Dat <br /> Additional Comments: <br /> II i <br /> ❑ Stk 466-6781- ElLodi 368-3621 ElManteca823-7104 ❑ Tracy j <br /> Applicant- Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED SY DATE RERMIT`NO. <br /> + <br /> EH 4-28 <br /> EH 13-24[REV. <br /> t <br />