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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZEL T ON AVE., STOCKTON, CA N O Li <br /> (209) 466-6781 n � <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. tF <br /> Job Address Jl')��k <br /> --.. City Lot Size PM <br /> Owner',s Name + '�1 N I d"Ck <br /> Address l0� SO r� � L4&3- 12—Phone <br /> Contractor=ATL �7" Address[�/�c� `" C,`, TIJ��D'7 _13 1 -3&4o <br /> License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL LJl WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. _ ��pFtOP. LINE"" <br /> FOUNDATION AGRICULTURE WECL'----7- OTHER WELL T PITS/Sumps <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ` CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well'Excavation Dia. of Well Casing J <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications JJJJi <br /> I'1 Public ❑ Other ❑ Delta Depth of Grout Seal s Type of Grout <br /> —_­ <br /> Depth I Irrigation _.Approx.:Depth I 1 Eastern �'«� Surface Seal Installed by T <br /> Repair Work Done ❑ Type of Pumps H.P. State Work Done _ <br /> Well Destruction Ll Well Diameter Sealing Material Itop 50'} <br /> Depth Filler Material (Below 501 "r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUC <br /> F TION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other f <br /> Number of living units: Number of bedrooms <br /> Character of soil-to a depth of 3 feet: ' Water table depth <br /> r <br /> SEPTIC TANK ElType/Mfg 1 Capacity— No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> *' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: 'Well � <br /> Foundation Property Eine <br /> SEEPAGE PITS I 1 Depth <br /> —Size Number <br /> SUMPS ❑ Distance to nearest: Well 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 drdinances, 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 this permit 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 4 <br /> certifies the following: ")icertify 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."p <br /> The applicant m st call #or all r uired inspect ns. Complete drawing on reverse s^ <br /> Signed X23 Title: <br /> Date: <br /> OR PARTTM-ENNTT�USE ONLY <br /> Application Accepted by � " ,��, Date. b Area <br /> Pit or Grout Inspection byDate -�. Final Inspectionsby Date ata i�' <br /> Additional Comments:- r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑-Nfanteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copiea-to. Invironmental-Heatth Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED j <br /> INF CASH RECEIVED BY DATE PERMIT'NO. t <br /> + EH14-24iAEV.iiHs `� �' sC1 lob Jf r 16­0 UJ <br /> EH f4-28 U •t!u <br /> F.. <br /> t <br />