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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone {209) 466-6781 at <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> J (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 /> t Local Health District. / <br /> F Job Address 3q-3J City a&a0Q10 Lot Size_ ryL' PM <br /> Owner's Name 1 Y�Wt9�� Addresses`- ` Phone gcof- <br /> Contractor Address_ License No.305 17V <br /> TYPE OF WELL/PU P: NEW{'WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALIa4TI�N ❑ f'SY-ST-EM-REPAIR--Q--- _,, OTHER 0 <br />{ DISTANCE TO NEAT EST: SEPTIC TANK SEWER LINES . DISPOSAL FLD.. PROPA LINE <br /> FOUNDATION I �IAGRICULT f RE WELL OTHER WELL f PITS/SUMPS <br /> INTeNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF,&, IONS <br /> ❑ Industrial ❑ Open Bottom F1Manteca r Dia. of Well Excavation - Dia. of Well Casing <br /> ❑ Domestic/Private€w C1Gravel Pack C] Tracy \`-Type,of Casing Specifications <br /> f I PubliUN <br /> C P F1 Other Cl Delta Depth of Grout Seal �'�""�<� Type of.Grout <br /> I I Irrigation , --Approx. Dep33 v ( I Eastern Surface Seal Installed by <br /> Repair Work Done ;El Type of Pump i ✓ H,P. State Work Done <br /> Well Destruction l❑ Well Diameter Sealing Material itop,50�') j <br /> «} Depth Filler Material (Below 10177 <br /> -� 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.11R-RAR/ADDITION I DESTRUCTION I ) INo septic system permitted if-public sewer is` <br /> I} ° -available within 200 feetf) <br /> Installation will serve: Residence Commercial --. Other <br /> t Number of living Its: w�IVumber of ooms 3 ` <br /> 1 ��. <br /> Character of soil tk depth-of 3 feet. ` *° Water table depth ' `4 <br /> L SEPTIC4TANK LtYTypelMfg >F'� t� panty No. Compartments — <br /> PKG. TREATMENT PLT. ❑ `8f Method of Disposal- . <br /> I Distance to nearest: Well o r Foundation ProoLplerty Line <br /> LEACHING LINE P+' No. & Length of lines __..__, 5d Total length/'S'idggg Vo 7 i 'a <br /> FILTERBED' ' ❑ Distance to nearest ( <br /> Well�0 Foundation f Propeny�Line <br /> ' r <br /> SEEPAGE PITS I�Depth �c`S f � <br /> Size—� . 6 Number <br /> SUMPS( 4 Cl Distance to nearest: q Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ I 745-/ <br /> I'herebyfcertify 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-anti regulations of the San Joaquin1.Locai Health Di'btrict. <br /> Home owner'or licensed agent's signaturef'Wrtifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subiect to workman's compensation laws of California." Contractor s hiring or sub contracting signature <br /> certifies;the following.;-"I certifytgat inFthe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion law's of California." e <br /> The applicant must All for apse edctions. Complete drawing on reverse side. <br /> Signed X J Title: Date: <br /> 1�. <br /> ► /) FOR DEPARTMENT USE ONLY { <br /> I �`J r <br /> Application Accepted by Date/ p Area <br /> or Grout Inspection by G ate f/ Final Inspection by ! r Date/./ <br /> AdditioaT Comments: <br /> .- t <br /> f <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑'Manteca 1323-7104't\ •?`O` racy''835"6z385 a/WC <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 21b 5tk., 1 '!�fly <br /> L" r <br /> _-FEE._; AMOUNT DUE -AMOUNT REMITTED CK RECEIVED BY <br /> INFO ,may C Ii DATE PERMIT*NO. , <br /> t.EH13-241REV.rin5) -/ 9 ?�,Oc) /•`` <br />