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APPLICATION FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . PAYMENT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA a,. <br /> Telephone (209) 466-6781 RECEIVED <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED APR 2 5 19.10 <br /> ,I <br /> (Complete in Triplicate) SAN J{}A (iIN CQlJNTY <br /> Application is heleb made to theiSan Joaquin Local Health District for a permit to construct and/or install t y ] I ton is <br /> made in cor�pkiance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th e]fu't� L( � � quin <br /> Local Health District. / Sr II <br /> � T <br /> Job Address City Lot Size PM <br /> ` �fIM�� 1 c- n_ n q <br /> Owner's Name M. 1/�7�2 �"� Address ,'�! PhoneZ��^ FY1� <br /> CA <br /> Contractor Address.]q7 C-6'14-e- f 6 Li9cense No.(1`� qtJ/i�Phon 3-)2_ 30 <br /> TYPE OF WE il. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I� <br /> PUMP INSTALLATI ❑ SYSTEM REPAIR ❑ OT41R ] ��L fit Ind S <br /> DISTANCE TO NEAREST: SEPTIC TAN ft SEWER LINES *" 0 DISPOSAL FLD. PROP. LINE � <br /> FOUNDATION AGRICULTURE WELL U OTHER WELL2' ' PITS/SUMPS <br /> INTENDED USE TYPpE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II ! <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing AM <br /> L7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public p;.Otlher��ILIAD ❑ Delta Depth of Grout SeatType of Grout _. <br /> I I trfigation —.-Approx. Depth I I Eastern Surface Seal Installed by �M _ <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done _ �M <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 501 �M <br /> Dep1hi Filler Material (Below 501 �M <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> IN available within 200 feet.) <br /> installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> k Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> �M <br /> PKG. TREATMENT PLT. ❑ I� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1M ,� <br /> LEACHING LINE ❑ No. & Length of lines Total Length/size �M <br /> FILTER BED ❑ distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation- Property Line <br /> I DISPOSAL PONDS ❑ II. �. <br /> I' 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 regulations of the San.Joaquin Local Health District. 11 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit!L issued, I shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify tlhat in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion taws of Califor ia." ILII <br /> The applicant. ust all for req u' speCti4 s. omplate drawing on reverse side. �' <br /> /9() <br /> Signed X IM Titter Date: Z <br /> I� FOR DEPARTMENT USE ONLY <br /> Q� 1.�3z <br /> Application Accepted by 'G�" Date a Area <br /> Pit or Grout Inspection by Date R /91 7Q Final Inspection by d� Date a <br /> Additional Comments: <br /> ❑ Sik 466-6781 ❑ Lodi 1369-3621 ❑ 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 /> FEEINFO AMOUNiT DUE AMOUNT REMITTED K }1 RECEIVED BY DATE PERMIT NO. <br /> . rHt3-24{REV., y s <br /> EH to-2s 1� ] o© `� S <br /> � IM <br />