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�- <br /> Q�5' APPLICATION FOR PERMIT II <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I� <br /> 1601 E. HAZELTON AVE., STOCKT0IV, CA <br />/ _1 Telephone {209) 466-6781 I <br /> 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ` ��y} /�- /� l <br /> Job Address' 3 O `' Cl / l � Cite~`- ` �`"�Lot Sizer 6 3 A'�, PM <br /> Owner's Nam cless _ 44'31,11 r PhBiie� S <br /> -T, 1 t , <br /> Contractor Address License No. Phone <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE )0 F <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION r f <br /> ❑ Industrial ❑`Open Bottom ❑ Manteca Dia. of Well Excavation U ia. of Well Casing <br /> ❑�omestic/Private ❑ Gravel Pack ❑ Tracy I1 Type of Casing V �� t —Alcification `1 <br /> f Public Other el <br /> fj/L�l depth of Grout Seal ) ypg of Grout <br /> I 1 Irrigation _Approx. pth I I Eastew Sud ce Seal Installed by •�[ _ <br /> Repair Work Done ❑ Type of Pump H.P. / 'f State Work Done <br /> Well Destruction ❑ Well Diametert!n �f Sealing Material (top 50') <br /> Depth a Filler Material-(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is I <br /> available within 200 feet.) i <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: Water table depth ) <br /> i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> Distance to nearest: Well 'Foundation Property Line <br /> t <br /> i <br /> LEACHING LINE ❑ No. & Length of lines t Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t <br /> i <br /> 1 <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r -e <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 law`s, and <br /> rules and regulations of the San Joaquin Local Health District. i <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.n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting si4nature <br /> certifies the follow g: "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 Cali nia." <br /> The applicant snt.call for alh�egt,'yed ins ti s Complete drawing on raver <br /> Signed X /" - - ' �I1 Title: Dat <br /> FOR DEPARTMENT USE ONLY { <br /> Application Accepted by r Date �1 �A `ea j <br /> Pit or Grout Inspection by Date ` Final Inseection by �'ly Date <br /> Additional Comments: ✓` �� <br /> ❑ Stk 466-6781 ❑ Lodi 369-36A O Manteca 823-7104 t❑ Tracy 835-6385 <br /> Applicant Retur all copies to: Enx20 <br /> Environmental Heeaajth Permit/Services 1601 E. HazeIt n Ave., P.O. Box 2009, Stk., CA 91 r� p <br /> G�/I1 ` GG�f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.j <br /> —1 Oct <br /> ♦.EH1 -24tREV.r�n5Y �lt <br /> EH 144-29 <br />