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s APPLICATION FOR PERMIT <br /> E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> 11 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 /> Job Address <br /> vfrinzeCity F400L+Qkn 7 Lot Size PM <br /> Owner's Name �ej U011 ;'(dress <br /> � Phone <br /> Contractor Address Sllb License No..�� hortf✓ �- <br /> 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER y So <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOLJNDA ON AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE L PROBLE AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma ca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/ ivate ❑ Gravel Pack ❑ T acy ung 'Specifications /�Qf{rp. <br /> iw. <br /> `i Public C�f] Qther r� Delta Deptth.oL Grout eal D fo 6►+ O " ,r r of Grou<iZ"r <br /> ' 1 I I"0 Fon f[J Approx. Depth I Eastern Wit]L�I 'f/' I <br /> "yyy`E8 Rep ' Work Done ❑ Type of Pump H.P. State Work Done <br /> ILr` W I Destruction ❑ Well Diameter Sealing Material (top 50'I <br /> Depth I Filler Material (Below 501 <br /> TYPE OF"SEPTIC WORK_ NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted ifpublic wer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_'" Commercial_ er <br /> Number of living units: Number of bedroo <br /> k Character of soil to a depth of 3 feet: Water table depth <br /> E- SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> �{ <br /> P �.. i <br /> DiZnceonearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & ngth of lines Total len ae <br /> � P <br /> FILTER BED ❑ D. <br /> ante to_nearest: - Well ' Foundation Property Line <br /> SEEPAGE PITS [ I Depth Size Number <br /> SUMPS "" ❑ Di nce to nearest: Well Foundation perty Line - <br /> DISPOSAL PONDS ❑ <br /> 1 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 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� ch this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation <br /> .. 1 o ensation laws of Califor ' <br /> p 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 empioy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu for all required ' cti Complete drawing on reverse side. <br /> ('f <br /> Signed Title: <br /> e: Z� <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 <br /> j Applicant- Return all copies to: Environ mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO �AMOUNT[)UE AMOUNT REMITTED CK 4 CASH RECEIVED BY - DATE PERMIT NO. <br /> -EH 13-24(REV.1/H 5) <br /> EH 14-26 <br /> F <br />