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APPLICATION FOR iPERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> r 011. Vi� t (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 Heaith District,:+~1!> <br /> Job Address '5O/ d ' 's' +^m �o '�' City + d •ow Lot Size PM 11 <br /> Owner's Name T b 0 r�"'hOn, Address f' 6"'_. Tre ` Phone i <br /> Contractor's Name ��' Iz.IjAdC ° Co..3License No. � 70d"I Phone d' 7g�1 <br /> TYPE OF WELL/PUMP:: +;, NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ria. of Welt Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. ....Type of Casing Specifications r <br /> ❑ Public ❑ Other s (].Delta, Depth of Grout Seal Type of Grout (A <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> i Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTAL )Z REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is vi <br /> t available within 200 feet.) <br /> Installation will serve: Residence_Y_ Commercial_ Other <br /> I Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: S �- Water table depth <br /> SEPTIC TANK Type/Mfg /mat ��" ^`F Capacity 0a 4/ No. Compartments-. ., <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal j <br /> p Distance to nearest: Well =Foundation i Property Line <br /> 3 X �Xo / <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED 17Distance to nearest: Well C­1 <br /> Foundation Property Line <br /> SEEPAGE'PITS ❑ Depth �a Size "7 xy Number <br /> SUMPS Distance to nearest: R Well 4?' foundations Property Lin <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 /> rules and raguilations of the San Joaquin Local Health District. ` ' <br /> Home owneror licensed agent's signature certifies the to4l6wing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> —employ as to became subject-to workman's compensation-laws of Cal'rfornia." 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'laws of.California.:'.��.. <br /> The,applican ust call ail r quir inspect; ns. Complete drawing on reverse side. <br /> Signed i c Title: f`:' 'r Date: 57^ <br /> v FORDEP TMENT USE ONLY <br />' Application Accepted by v�' Date r �� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 15E t fa <br /> ❑ Stk 466-6781 - ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> " FEE <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> +EH 1'3-24(REV.10183! � ` <br /> EH 1428 <br />