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APPLICATION FOR PERMIT PAYMENT <br /> I' SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 0 C T Z 9 <br /> SAN JOAQUIN COLI<tl'r'V <br /> PERMIT EXPIRES 1 YAR FROM DATE ISSUED <br /> ;( PUBLIC HEALTH SER'v,-;-.S <br /> i (Complete in Triplicate) ENVIRONMENTAL HEALTH Glk'�QN <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 Joa uin County Ordinance No.549 f r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.�a d -77(9+:)_6 ,?61` I <br /> Job Address ����� � ,r &J&;&AS City Lot Size PM < <br /> Owner's Name C►toa,60I1Addres I y C�hone4 <br /> Contractor Address` a0 icense'1Vo: rf*v I <br /> t � <br /> ane �'��� <br /> TYPE OF WELL/PUMP: NEW WELL p r,1.WELL-,REPLACEMENT ❑ DESTRUCTION Cl <br /> PUMP INSTALLATION ❑" "` SYSTEM REPAIR ❑ " OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK _. SEWER LINES 7� DISPOSAL FLD. r� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL —5-S_ WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> a <br /> ❑ Industrial �❑/Open Bottom ❑ Manteca Dia. of Well Excavation �f Dia. of Well Casing <br /> lot <br /> ❑ Domestic/Private A Gravel Pack ❑ Tracy Type of Casing Pw Specifications �S �` <br /> Cl Public M 01her Ll Delta Depth of 6*91PtSeal — Type of Grout i'c <br /> I Irrigation 2s pprox. Depth I ] Eastern tiir talleci by - <br /> Repair Work Done ❑ Type of Pump � H•P if . State Work Done <br /> Weil Destruction ❑ Well Diameter Z11 Sealing Material (top 50'� t <br /> ic <br /> Depth - a Filler Material (Below ) — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I ) DESTRUCTION l I (No septic system permitted if public sewer is <br /> II available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: 11 Number of bedrooms yJ <br /> Character of soil to a depth of 3 feet: Water table depth # <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> � I <br /> Distance to nearest: Well Foundation Property line I <br /> LEACHING LINE ❑ Nb. & Length of lines Total length/size901 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number ,,0�/� <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line W <br /> u <br /> DISPOSAL PONDS ❑ t <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 SanJoaquin Local Health OiMfict. <br /> Home owner or licensed agent's signature certifies the following: "1 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 L <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." Ii. <br /> The applic all I required inspections. Complete drawing on reverse side. <br /> Signed Title: Gi zL,q4 MAua Date: L 0 <br /> �I OR DEPARTMENT U ONLY <br /> Application Accepted by Date Area <br /> Pit or ro Inspection by Date 2 0 Final Inspection by "mss Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi i 369-3621 ❑ Manteca -7104 ❑ racy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009,Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ­EH13-24(REV.11H5) 4 �(vC.� (�C� � 1 <br /> EH 14-28 )` C,> <br />