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4 <br /> k APPLICATION.FOR PERMIT ] <br />' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.-STOCKTON, CA <br /> Telephone 12091 466-6* , <br /> ,F r <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> E, ,.X7' (Complete in Triplicate) f <br /> C 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 /> a 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 /> ] (f t <br /> Job Address / A C) i�" City+ t 0 Size PM <br /> S l a iE t:iii <br /> ■ w <br /> Owner's Name Address !t"A 11"bt-ate Phone <br /> Contractor Address .y :_ License No.. Phone <br /> TYPE OF WELL/PU P: NEW WELL-0 WELL REPLACEMENT ❑ DESTRUCTION:.❑-�_ - <br /> PUMP TALLATION-,❑ SYSTEM REPAIR*❑. OTHERS` s ' <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPO PROP LINE <br /> FOUNDATION AGRICULTUR OTHER WELL PITS 5U_MPS. <br /> _ i <br /> �_ _ ¢ <br /> INTENDED-10SE TYPE OF WELL PROAL CONSTRUCTION SPECIFICATIONS--•E...., <br /> ❑ Industrial~ ❑ Open Bottom anteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ T If Type of Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by I <br /> Repair Work Done Type of Pump H-P. � State Work Done_ � ~` <br /> ss 1 a <br /> Well Destruction Well Diameter Sealing Material (top 50'1 <br /> Depth #t Filler Material (Below 501 . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONA (No septic system permitted if public sewer is <br /> available within':200,feet.) {� <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms E �i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity f4"4*_**"4'1wNo-Compa4"nts <br /> PKG. TREATMENT PLT- 17Method of Disposal <br /> Distance to nearest: L3,11 Foundation ' Property Line <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size # <br /> } FILTER BED * ❑ distance to nearest: Well - Foundation Property Line � <br /> ft I <br /> SEEPAGE PITS ❑ Depth Size Number �f <br /> _SUMPS �3 4 i] Disfance to nearest: We11 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 regulatioris of the SariJoaquin Local Health District. ITi t <br /> i 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 ofkCalifornia."Contractor's hiring or subcontracting 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 orkman's compensa- <br /> tion laws'of Californ`ia." <br /> IP <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> d <br /> Signed X ` E 5 t1C. Title: 1' Date: <br /> ILORD PARTMENT USE ONLY T <br /> .Application Accepted by Date - / Area- <br /> e�.r... c,.(U Ic ( Ov u g PG-'o—, <br /> ` Pit or Grout Inspection by Date Final Inspection by- Date <br /> —12- <br /> r <br /> Additional Comments: 7 <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTEp RECEIVED 13Y PATE PERMIT N17. <br /> l INFO '` CASH �f p (� <br /> 't.EH 13-241REV.I/'Efs) .' - 3s- OV -r~''7 F14 r . <br /> I EH 14-26 <br />