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{ , 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 /> ".- �j <br /> Job AddJress J - • d� -y- v City toC 6r-Lot Size PM <br /> Owner's Name 'I Address 5 /W -"Q- Phone Ya,o <br /> Contractor 4 �)_ Address S License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> , INTENDED USE TYPE OF WELL PROBLEM'A'REA­CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca orf Dia.-of Well Excavation Dia. of Well Casing ry <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy j Type of Casing Specifications <br /> 1-1 Public i1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx. Depth l I Eastern'"`'""'",SDHace Sea l'lnstalled by " <br /> ___- <br /> Repair Work Done ❑ Type of Pump H.P. \` State Wark.-D�one_ <br /> Well Destruction ❑ Well Djameter Sealing Material (top 501 <br />' Depth t Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION1b1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other �+ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet r Water table depth _ <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ x 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 Foundation Property Line <br /> SEEPAGE PITS FI Depth I Size "Number <br /> SUMPS LlDistance to nearest: Well Foundation Property Line <br /> E DISPOSAL PONDS ❑ I <br /> I hereby certify that t 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 D;tridt. <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." Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws~of California." <br /> The' <br /> applica t4" ust call for all equ'ed Yn. tions. Complete drawing on reverse side. <br /> d`�Signed X Title. Date: ` r <br /> G � <br /> t FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Ins y "'" <br /> pecti 1 b 0 Date Final Inspection by Date J <br /> Additional Comments: v 6 <br /> ❑ Stk 466-6781 ElLodi„369-3621 BMs eca '' "r-7 <br /> cy,L$35- 5 `'• •++• Lam: #74 <br /> Applicant- Return all copies to: Environ <br /> mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24(REV.vH5) j ,/ <br /> EH 14-29 '";r' �;' -7 t- 171 17 a <br />