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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. i-IAZELT ON AVE., STOCKTON, CA <br /> Telephone 1209) 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 /> 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 �ry`r Z/ Go (1,4- '7-1 City ^ *W?F" Lot Size_ PM <br /> Owner's Name .e!� r�.�11rLi+*A_ � Address SAV 2 Z4 Phone <br /> Contractor T 4 .C, `/ Address License tufo. A��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION.171 SYSTEM REPAIR. © BOTHER LJ <br /> DISTANCE TO NEAREST:-SEPTIC�TANK� `, C. SEWER LINES DISPOSAL,FLD PROP. LINE r <br /> FOUNDATION AGRICULTURE,WELL OTHER WELL PITSISUMPS <br /> i <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS i, <br /> ❑ Industrials T Open Bottom`L ❑ Manteca r Dia. of Well Excavation Dia. of Well Casing r <br /> .n <br /> ❑ Domestic/Private LJ Gravel Pack ❑ Tracy Type of Casing �' Specifications <br /> 1`1 Public A CJ Other C1 Delta Depth of,Grout Seal Type of Grout _ <br /> I I Irrigation __Approx._Dep_tiI I Eastern Surf e-Seal l -Stalled by <br /> H.P. <br /> Repair Work Done C7. Type of.Pump State Work Done <br /> Well Destruction HCl Well ff meter �" e� x� Sealing Material {top <br /> Depth f �` Filler Material {Below 50')_- I <br /> TYPE OF SEPTIC WORK: NEW'INSTALIlA71ON t.REPAlFj2ADDITION l I- DESTRUCTION I I (No septic system permitted if public sewer is <br /> ,/' "- �"' available within 200 feet.) �•l <br /> Installation will serve: Residence!' `,� Commercial_ Other <br /> Number of living.-units: 4-- Number of bedrooms <br /> Character of soil'to;a depth,of 3 feet: "" Water table depth 1 <br /> SEPTIC TANK° Ll r Type/Mfg Capacity No. Compartments r ] <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> _ , F. 7r <br /> Distance to n�rest: WelFoundation�� Property Line A!:) <br /> LEACHING„LINE No f& Length of linesrT Total length/size /,,-go /.:--7 <br /> r4yt <br /> FILTER BED LJ Distance to nearest: Well u`ndation7l2g�---Property Line00 <br /> r <br /> SEEPAGE PITS i I Depth �r� Size ,�� Number j <br /> SUMPS � Distarnce to nearest: Wel! Foundation,J(!,0101— Property Line �— <br /> DISPOSAL PONDS ❑ <br /> Ji j <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 <br /> rules and regulations of the San Joaquin Local Health District ` <br /> Home owner or licensed agent's signature certifies the following:"I de -in the performance of the work for which this permit is issued, I'hall not <br /> employ any person in such manne as-to become subject to workman's compensation laws of 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 laws of California." \\ i <br /> The applicant must call for II required inspections. Complete drawing.on reverse side. fff# <br /> 1 <br /> Signed X ' + t �Titlel .�ttn l J t Date: <br /> � t <br /> OR USE Y <br /> Application Accepted by Date Area / <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: t <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.-9ox_20W,.Stk.,_'Q 95201 <br /> {* 'INFO —AMOUNT DUE "AMOUNT REMITTED 4 CASH r RECEIVED BY DATE ?ERMIT'No. <br /> + EH 14-24 IREV. <br /> EH 14-2r1 � � J <br />