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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR'FROM DATE ISSUED " <br /> (Complete inrTriplicate) <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 Ryles.and Regulations of the San Joaquin <br /> -Local Health District. <br /> Job Address / C��' "' l City eS � kot Size` s PM <br /> Owner's Name _Cf fA L Address t; 7- (fX Vim' de(f o (I---Phone <br /> Contractor moi: Address14(fLicense No. — Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER EI <br /> EW <br /> DISTANCE TO_NEAREST: SEPTIC TANK SER LINES,%%" � -''iDISPOSAL)FLD. -PROP.-LINE ,R <br /> -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> - <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial, i' ;- `'� 0'Open' Bottom w•❑ Manteca Dia. of Well Excavation Dia. of Well Casing qq� <br /> ❑ Domestic/Private ❑ Gravel Pack-. �` O'Tracy •– Type of Casing w. t Specifications t <br /> ` ❑ Public -£ ? ❑ OtFier` ❑_Delta I Depth of Grout SealType of Grout <br /> El irrigation --Approx. Depth El Eastern Surface Seal Installed by I E <br /> e r <br /> Repair Work Done ❑ �Type'of•Pump. H.P. State Work Done_ <br /> Well Destruction [IWell Da'meter� '� 11;Sealing Material (top 50') <br /> i Depth Filler Material (Below 501 <br /> TYPE OF�SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No-septic system permitted if public sewer is <br /> $ l available within 200 feet.) <br /> x � jffV►.IJF� <br /> Installation will serve: Residence-•— -Commercial_ Other >'�� L <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ter table th 77 <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments, <br /> PKG. TREATMENT PLT. ❑ ` Method of Disposal U JW <br /> Distance to nearest:; ` /yell / d Foundation ._.,__.__ Property Line J Q <br /> l <br /> LEACHING LINE d No. & Length of lines " 4°r Total length/jsize <br /> FILTER BE© ❑ Distance to nearest: Well 1 3� Foundation Property Line <br /> SEEPAGE PITS 01 Depth 1 Size 7 Number 1 <br /> SUMPS ❑ Distance to nearest: Well Foundation"~ a '� - Property Line <br /> Ll _ <br /> DISPOSAL PONDS .t R <br /> 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. ; I <br /> 1,1.r 4-'Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner,asto 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." �d <br /> The applicant must.call for all eq ' spections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> t <br /> } _ FOR DEPARTMENT USE ONLY <br /> XIS-Aaafiwtion Accepted-byr r'�`�' Date Area <br />' ' r _. ,.. 1 � � 5 <br /> Pi rout lnspectia'n by -�� u ate i -final Inspection by .l_ t Date ' <br /> •,e.�„ rid W '.o ,q in ►ti o iT— A <br /> E1d_ditional,Comments:,, <br /> I > <br /> i Stk 466-8781 ❑ Lodi 369-3621 Manteca' 823-7104 ❑ Tracy F <br /> I Applicant= Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201' <br /> 1 FEE � '! <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV.1/65) } 5 <br /> EH 1426 - / <br />