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APPLICATION FOR PERMIT a ' <br /> k SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> { 1601`E,HAZEL: OWN\AVE..,-STOCKTON, CA ' <br /> fl i <br /> Telephorie (2091 466-6781 ��� �' 19,��,� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) ENVIRpOt`MI7E!/`+NEAR HEALTH <br /> rF tY1629 sg 'VICES. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei s 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 /> I Local Health District. <br /> fv <br /> � gs�zl <br /> Job Address <br /> +� -oopDOLIL a City Size PM <br /> o 4krgs� iz 3 _ lSIS'", <br /> r �' ��Q.th't� � . _ Phone <br /> Owner's N�m-llAddress �j h <br /> Contracto Address O �i_ iC ` 1 _License No. [ �� `,3Phone <br /> k TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION (71 SYSTEM REPAIR f� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <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 Specifications <br /> {-1 Public ❑ Other F1Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I 1 pastern Surface Seal Installed by <br /> 14 A <br /> Repair Work Done R+/ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION 11 EIEPAIR/ADDITION 1 i DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence JComme{{rcial Other <br /> Number of living units: Number-of bedklms �` <br /> Character of soil to a depth of 3 feet: �" ^'+` l Water table depth <br /> / �� � ��-`` r �I� No�Compartments <br /> SEPTIC TANK ❑ Type/Mf Capacity - <br /> PKG. TREATMENT PLT. ❑ Jj,2_ F yr `'�-Method of Disposal <br /> Dis ante t nearest: Well Foundation Property.Line�- <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE_ PITS l I Depth Size Number <br /> } SUMPS Cl Distance to nearest: Well Foundation Property Line f <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 o San Joaquin Local Health DRtrict. <br /> Home owner or ii sed agen 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 pe on in such rna or as to b ome st-011 to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the f lowing: "I cern that' t or nc of the ork for which this mit is issued,I shall employ persons subject to workman's compensa- <br /> 4 tion laws o Califo i <br /> The appli nt 'all re f p t• ompl a drawing on r e i <br /> Signed X Title: Hate: <br /> I DEPARTMENT USE ONLY <br /> r <br /> Application Accepted Date AreaU. <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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. Box 2009, Stk., CA 95201 <br /> fi <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. <br /> INFO CASH <br /> a.EH 13-24 IpEv.1/"51. <br /> ' <br /> i EH 14-28 <br />