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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 /> t 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. 1562 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. "s <br /> �. r <br /> City Lot Size PM <br /> Job Address `r <br /> Owner's Name Address'` <br /> � k1, Phone <br /> �f`Address License No. Phone <br /> `Contractor <br /> i►�(PE OF WELL/PUMP: NEW WELL 1-1 <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TQ NEA EPTIC_TANNNK� SEWER LINES DISPOSAL FLD. PROP."LINEy t <br /> FOU I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 E <br /> (INTENDED USE TYPE OF WELL _ EM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Ling <br /> Type o Specifications <br /> ❑ 6omestic/Private4_ ❑ Gravel Pack ❑ Tracy T e of Groin <br /> ❑ Public G DEQ El Delta Depth of Grout Sea YP <br /> 1. <br /> ❑ irrigation �pprbx� Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done _� ?,ype of-Pump H.P. State Work Done <br /> Wel Destruction ❑ We11-Diameter Beaking Material (top 50'1 <br /> Depthp I Filler Material (Below 50') <br /> TY E OF SEPTIC WORK: NEW INSTA - I.�N �IR/ADDITION DESTRUCTIO (No septic system permitted if public sewer is <br /> ,r---- � � availa le within 200 feet.) <br /> Installation will serve: R -dente Commercial <br /> Numberl 6f living u�ts{s 7 . Number of bedrooms cCharaalv� <br /> sof oi�to,a depth of 3 feet:— fr ,` <br /> Water table depth <br /> t "-°� a/Mf z Capacity/�► No. Compartments <br /> i SEP, ICTANK ❑ TYq 9 <br /> i j Method of Disposal <br /> PKG.Wfi A`TMENT PLT. ❑ ``", ' <br /> } : Distance to nearest: Well Foundation Property Line <br /> ' LEACHkNG LINE ❑ No. & Length of lines p o I length/size <br /> FILTERBED <br /> ❑ Distance to nearest: Well S7�� Foundation� � Property Line <br /> t ' <br /> SEEPAGE PITS ❑ Number <br /> Depth ` S Siie <br /> SUMPS, ElDistance to nearest; Will f Foundation iV Property Line <br /> DISPOSAL PONDS ❑ <br /> I herebyicertify that I have prepared this applicabi n and th4at the w'&k will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and`regulations of the San JoaquinfL&I'll4galth Distrilct-" ' <br /> Home ownk.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 /> } <br /> employ any pesos in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the followig,,"I certify that inithe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- k <br /> tion laws of Ca{ifbrni&. A <br /> The applica musttisaall for a quired"inspections. Complete drawing on reverse side. <br /> t Si sed X L Title: ®.C�t M J{•Ji Date: <br /> 9 <br /> `1FaR DEPARTMENT USE ONLY i <br /> Date <br /> Q"�lA Area Q i <br /> t )(cation Accepted 1 <br /> Da etet Final Inspection by Date 1 ti��a v '� <br /> Pit r Grout InspectionI by � lD~�a <br /> Additiondt.Com mnfti: . b <br /> El Stk 466= 751 1-1Lodi369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <br /> Applicant- Retu n .II conies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # <br /> > GK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> d�to� � Sb <br /> a+ EH 1324(REV.1 a 5) <br /> EH 14-26 - - ` <br />