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j APPLICATION FOR PERMIT'. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> t 1601 E. HAZEL T ON AVE., STOCKTON, ,, <br /> Telephone (209) 466-6781 �,ccR�Al <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE IRS/-,/N),Q� <br /> (Complete in Triplicate) <br /> �/� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ibedf .'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 /> Q� !— t D r <br /> E Job Address �/ a �� G . F-Lr. City Lot Size PM <br /> Owner's Name�C��t�il�F_ fit` Address 51?95 6 E�<Qk­ Mi Phone 033 <br /> LI <br /> Contractor13 Address License No.n'e0,5L(I Phone! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' <br /> FOUNDATION`!-- AGRICULTURE WELL OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE-OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! r <br /> ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications oQ <br /> ublic 0 Other Cl Delta Depth of Grout Seat Type of Grout _. <br /> 1 6gation _Approx-9epth----1-I-Eastern- r =rSudace-Seal-Instaiied by _ <br /> epair Work Done ❑ Type of Pump 5 H.P. .3 -State Work Done . <br /> Well Destruction ❑ Well Diameter Sealing Material itop'50') <br /> -"p813th filler"tvlaterial-lBaiow-50' _ k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is <br /> I tt available within 200 feet.) t'� <br /> Installation will serve: Residence_ .Commercial— Other <br /> { Number of living units: Number of bedrooms w <br /> Character of soil to a depth of 3 feet: Water tablet depth P <br /> SEPTIC TANK ❑ Type/Mtg N \ ompart�mentsp _ <br /> PKG. TREATMENT PLT. ❑ {r <br /> Method of Disposal __ h <br /> y` p <br /> Distance to nearest: Well Foundation Property Line. l <br /> LEACHING LINE ❑ No. & Length of lines _._. _._. Total lengthtsize_____ <br /> FILTER BED 1 ❑ Distance to nearest: Well _ Foundation Property Line <br /> SEEPAGE PITS I'I Depth Size _._ Number <br /> r I r <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 ordinances, state laws{, and <br /> i rules and regulations of the San Joaquin Local Health Diktrict. } <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 uch manner as to become subject to workman'a compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the followin : 'I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's com. nsa- <br /> tion Taws of Ca <br /> The applicant us all for all require - spection omptete drawing an revs se side. D <br /> Signed X _ Title: O Date: <br /> t F R D ARTMENT SE ONLY <br /> Application Accepted by Date P'-:;11 2L ! Area P <br /> Pit or Grout Insoectioby ateFinal InspectinC� 3 <br /> Date <br /> 1 r 1 <br /> Additional Comments: t 1 <br /> ❑ Stk 466.6781 ❑ Lodi 369-3601 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEi <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY �} DATE/ r PERMIT No. <br /> EH 13-2 (REV.»n 5: ��^ N <br /> , EH 1446 (((��� CCC.••JJJrrr <br /> 1 _ <br />