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SS �; <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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.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 a 4e - <br /> LJobddress 3� 3 S 1 city S 7�69 AL Size PM <br /> r's Name Address o2�� � y /�f Phone —actor `"""""Address *..G ►i. L-ice se No. Phone_ <br /> TYPE OF WELL/PUMPU NEW WELL ❑ —WELL REPLACEMENT ❑ -Q ,A DESTRUCTION <br /> PUMP INSTALLATION'❑ +� <br /> SYSTEM REPAIR ❑ 0TH ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 DISPOSAL FLD._ ,PROP..,LINE. <br /> I MM– FOUNDATION AGRICULTURE WELL yOTHER WELL PITS/SUMPS <br /> �:. I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑? El <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Specifications , <br /> t. <br /> ❑;Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> EJ'Irrigation Depth . 1-1EasternSurface Seal Installed by <br /> Repair Work Done ❑ Type ype r i.n ' <br /> p �_�� . of Pump / H.P. State Work O ne <br /> Well Destruction ❑ Well'Diameter Sealing Material (top 50') <br /> • Depth Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> R <br /> Number of living units: Number of bedrooms !• <br /> Character of soil to'a-depth of.3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments $ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number t <br /> SUMPS ❑ Distance to nearest: Well Foundation Properrt^ine <br /> DISPOSAL PONDS 7-11 J <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordancbJvith San Joaquin county ordinances, state laws and <br /> rules and regulations of the San Joaquin Local Health District.. t1.'� 1 <br /> Home owner or licensed agent's signature certifies the following: "I certifyfhat in the performance of the work for which this permit is issued, I shall not <br /> m <br /> eploy any person in such manner as to become subject to workman's compensation laws of California Contractor s,Kiring 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." <br /> The applicant m call fora squired inspect , Complete drawing on reverse <br /> verse side. <br /> xJ " Sig ed X Title: Date: <br /> .FOR DEPA T�MENTrUSE ONLY <br /> Application Accepted by / ! ` �_ Date Area <br /> Pit or Grout Inspection by "Date _ = Final Inspection by Dat l,Z— <br /> Additional Comments. <br /> ❑ Stk 466-6781 �Li -3621 ❑ Mantec 82-3-'7104 ❑ Tr 835-63% <br /> Applicant- Return all copies to: Environmental Health Permit/gervices 1601 Hazelton Ave., P.0 Box 2009FEE. , tk., CA 9 01 <br /> INFO. MOUNT DUE " AMOUNT'REMITTED ' CASH.. —RECEIVED BY DATE y.. iERMIT"NO. <br /> t <br /> + EH 1428(REV.}/h51 �J(/ <br />