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APPLICATION FOR PERMIT - <br /> VX/ _ 3(0 �3 <br /> SAN JOAQUIN LOCACH:EALTH DISTRICT <br /> 1601.,E. HAZEL T ONAVE:, STOCKTON, CA f r r <br /> -'""Telephone (209) 466-6781 <br /> PERMIT EXPIRES1 -YEAR=FROM-DATE ISSUED,' ` {y' <br /> (Cornplete,in Tripllcatel <br /> �,.A <br /> �pplrcation 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 Roles and Regulations of the San Joaquin <br /> Local Health District. <br /> � / OCity j . S"{i <br /> PMze <br /> Job Address r - r <br /> :.. u <br /> . ` <br /> ` <br /> %- F-0_47- - Address - . 4 AYt-LD L r�� Phone elr <br /> - Owner's Name es d <br /> µ /�v//�� .� / 7 License No. 66 Phone 6!' "7O 49 <br /> f Contractor 1�K Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIROTHER ❑ . <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ! Cl Indd trial L1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ? Type of Grout <br /> .�❑ Public 11 Other ❑-Delta Depth of Seal- YP <br /> El PProx. [ <br /> I Depth [JE stern S ace Seal Installed by ~f <br /> P � `I � <br /> Repair Work Done Type Of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 vQ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: - NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available,within 200 feet.) <br /> l <br /> Installation will serve: Residence_ Commercial— Other 0 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - .�. Water table depth <br /> SEPTIC TANK ❑ pe/M <br /> Tyfg _ Capacity-_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal = U <br /> Distance to nearest .. Well Foundation Property Line <br /> . I � <br /> LEACHING LINE ❑ ! No. & Length of lines Total length/size <br /> FILTER BED Eli,Distance to nearest: Wall` Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth' `"Size "Number <br /> SUMPS ❑ L Distance to nearest: Well Foundation _.Property Line , <br /> I DISPOSAL PONDS ❑ <br /> 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 re he San Joaquin Local Health District. <br /> Home ow r or licensed al nt'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 y person in such annex as to become subject to workman's compensation laws of'California."Contractor's hiring or sub-contracting signature <br /> certifie the following:"I ce fy that in the pert -mance oft ork for which this permit is issued,I shalt employ persons subject to workman's compensa <br /> tion la of Californi <br /> r The a plicant us aN requ' d o ate wing on rev/v side. <br /> Signed <br /> Title: - Date: /z <br /> } FOR DEPARTMENT USE ONLY <br /> Date Ar'ea <br /> Application Accepted by z ;_ <br /> Date Final inspection by '" <br /> "'Date AL <br /> ' Pit or Grout Inspection by - <br /> Additional Comments: <br /> M�Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009,.Stk., CA_°95201 ; _ rr) <br /> FEE, !AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE + .' ^•PERMIT.'NO.„t- <br /> - -INFO 1 <br /> I i i <br /> ' + EH 13-24(REV.S/65) w -- •-�-}- -.�- <br /> �,� t i <br /> EH 14-26 <br />