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l <br /> w <br /> APPLICATION FOR PERMIT <br /> ,-« SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �© <br /> Telephone 12091 466-6789 r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k a3�'dbJ�►n.�' <br /> (Complete in Triplicate) <br /> Application is hereby made to th4San 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address _ ( 1 5 j E V0-9,A L q I)r City S TAN Lot Size PM <br /> Owner's Name !'y _ ! i �'�� 1t:'[�NNEC1 Address r7 3 2- 5 e Phone f ~ <br /> f) N�1� �•�� Sbr gS License No. 2 G/ 4/3_ Phone K 9r�6 <br /> Contractor's Name ` <br /> TYPE OF WELL/PUMP: :I` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMI?l INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE _ v <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public T❑ Otfier _-0 Delta Depth of Grout Seal Type of Grout <br /> ❑Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type df Pump H.P. l State Work Done <br /> f, 1s r <br /> Well Destruction ❑ Well Diameter '' ! Sealing Material [top 50') <br /> r : <br /> Depth,k Filler Material-Weiow 501 <br /> TYPE OF SEPTIC WORK: NEV11•,INSTAELATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONA INo septic system permitted if public sewer is <br /> k available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: INumberof bedrooms i <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. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 i <br /> LEACHING LINE '❑ No it Length of lines Total length/size <br /> FILTER BED f❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS '❑ Depth Size Number <br /> SUMPS '❑ Distar ce,to.nearest. Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepaFred 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 this permit is issued, I shall not <br /> employ any person in such manner astobecome-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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m all for all rel.ui inspe ions. C mplete drawing on'reverse,side. <br /> Signed Title: - ►�f �� Date: �- <br /> FOR DEPARTMENT USE ONLY <br /> C? _� <br /> Application Accepted by U <br /> Date Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments4' <br /> ❑ Stk 466-6781 © Lodi{ 369-3511 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies <br /> to <br /> EEl <br /> Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE is"p,MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> EH 13-24(REV.10183) S /('D/TZ 7 �J...i <br /> EH 1428 <br />