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Yr �� <br /> APPLICATION FOR PERMIT <br /> F- � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �i0� r <br /> 1601 E. HAZE LTON AVE., STOCKTON, CA <br /> -T61W one (209) 466-6781 N alae, <br /> I PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> (Complete:in Triplicate) <br /> Application is hepeby 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 /> Job Address -a'oo S V'O �rd ` <br /> City .S y\1 Lot Size 1 Z 0 PM <br /> Owner's Name S1r\U��\ i� t Address <br /> Phy i <br /> Phone <br /> Contractor � Gj`,��•-�`T[S'r E r <br /> Address t. License No. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL-❑ ,, WELL REPLACEMENT❑ DESTRUCTION ❑ <br /> —PUMP INSTALLATION'❑ SYSTEMA REPAIR'O —'OTHER-'D <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca x Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal '' Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Sea! Installed by � <br /> Repair Work Done ❑ Type of Pump H.P. State Work pane_ { <br /> ' Well Destruction ❑ Well Diameter Sealing Material {top 501 li <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is jr1' <br /> I available within 200 feet.)` +• t 0 i <br /> Installation will serve: Residence— Commercial_ Other Q <br /> Number of living units: Number of bedrooms '"`�.,..•—_ <br /> Character of soil to a depth of 3 feet: k <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg � apa ity No. Compartments j <br /> PKG. TREATMENT PLT. Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines /�I <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well'+-- �F ndation Property Line J <br /> Q I <br /> SEEPAGE PITS ❑ Depth t Size Number + <br /> SUMPS ❑ Distance to nearest: Well "Foundation Property Line <br /> i <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 of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thispermit is issued, I shall not <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." <br /> The applicant r ups call for all r (red ins tions. Complete drawing on reverse side. <br /> Signed u-^— -< 0+t,3 V\c f <br /> Title: Date: 2�Z� <br /> PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final inspection by. Date ! � <br /> Additional Comments', <br /> ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑.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 9529 <br /> FEE AMOUNT DUE AMOUNT REMITTED Q� <br /> INFO CASH RECEIVED BY' DATE PERMIT'NO. <br /> r EH 13-24 SREV. <br /> EH 14-28. V �� <br />