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APPLICATION XOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA IVA <br /> Telephone (209) 466-6781 <br /> F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 " <br /> .(Complete in Triplicate) ix,•> tie <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. ((( z <br /> l Job Address <br /> City! Z� Lot Size GS' PM <br /> Owner's Nam Address `" - -- �- <br /> d� Phone _ <br /> i Contractor rens ! / <br /> License Nv. Phone <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i r— --�-----�---PUMP-INSTALLATION-I� SYSTEM-REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD, t <br /> PROP. 6INE,3 <br /> FOUNDATION---_ AGRICULTURE WELL 0 OTHER WELL <br /> _ PITS/ LLMPS-e <br /> INTENDED USE TYPE OF I PROBLEM AREA CONSTRUCTION'SPECIE/ <br /> ❑ Industrial <br /> ❑ Open Bottom-_ ❑ Manteca Dia. of . �tion Domestic/Private 12 Gravel Pack LJ Tracy Dia. of <br /> E3 Well Casing <br /> ype of Casing Specifications <br />� ❑ Publie I] Other � "'"' alta"'" `"-""'�'�peptF�of'Giout ��r � 9 <br /> ❑ Irrigation Type of Grout <br /> g r 4 ---AP i epth ElEastern Surface Seal installed by �� jF <br /> Repair Work Done ❑ of Pump f H.P. State'Work Done <br /> Well Destructio wig Well Diameter Sealing Material Itop 501I . <br /> Depths i Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D RUCTION <br /> '(No septic systefm Permitted if publicfsewer is <br /> � f= Vail, a within 2 'feet <br /> 'A7 will serve: Residence Gommercial Other <br /> h' i <br /> Number of living units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC/'TANK Capacit <br /> Type/Mfg <br /> PKG. TREATMENT PLT. 1 <br /> Water table depth 1 <br /> E y No. Compartments c <br /> ED , <br /> i 1 Method of Disposal <br /> Distance to nearest: Well -- Foundation TProperty Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ;_ EJ Distance to nearest: 4.1 Weil Foundation <br /> I { I Property Line <br /> SEEPAGE PITS ❑ Depth Size t <br /> Number <br /> SUMPS ❑ Distance io!nearest: �. Fodation Property Line <br /> DISPOSAL PONDS <br /> Well un <br /> ❑ ' I °i j <br /> hereby6certify that I have prepared this application and that the work will befdone in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations•of-the San„�Joaquin`,Local Health District. + ' f <br /> Home owner or licensed agent's signature�c�rtifies 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'o4 California."Contractor's 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 law_4 of California." <br /> The applicant ust call for ll require inspections. Complete drawing on reverse side. <br /> Signede <br /> I Title: { Date: S _ <br /> 40,, FOR DEPARTMENT USE ONLY <br /> Applicatin Accepted by EXU. Date ^�'b.� <br /> Area <br /> Pit or Grout Ins <br /> pection b Date Final Inspection by <br /> Date <br /> Additionl Comments: <br /> LlStk '+166 6781 "Lodi `369=3621' "11�fanteca 823-7104 :❑ Tracy 835-6385 --- - f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., GA 95201 i <br /> FEE AMOUNT DUE AMOUNT REMITTEp <br /> INFO CASH RECEIVED BY DATE. PERMIT NO. <br /> + EH 1 -241REV,rias) _ - - ^ -� <br /> EH 1426 �'9��,J <br />