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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA 1. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> I 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 /> .lob Address 12 `Y" /1 ACE/VICWX City Lot Size PM <br /> Owner's Name Addressrsf/f e �� <br /> h <br /> AdtlLiceris, No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: ��.NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEARESTASEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ! , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> iINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ilndustrial D Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑[Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'i Public F1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> rrigation _____Approx, Depth 1 1 Eastern Surface Seal Installed by �i <br /> �� <br /> tir Work Done d Type of Pump ��1 JIV H.P. B State Work Done F/ <br /> �7_ / <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth _ Filler Material (Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION Ll DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> In stallation will serve' Residence_ Commercial_ Other 0 <br /> f _ J <br /> Number of living units: Number of bedrooms <br /> Character of,soil to I depth of 3,feet: Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments <br /> PK' TREATMENT PLT. ❑ Method of Disposal <br /> ' �f <br /> t1 j pi ante to neatest: Well Foundatidn _Property Line � <br /> LEACHING LINE L Ll Not & Length of lines ` 4Z Total length/size <br /> FILTER BED <br /> : f-`O. Disltance to nearest: ----Well Fou dation'" '" Property Line m <br /> ` <br /> 4 <br /> ]rr S&AGE PITS €—l.l_=E�epth I -size t'3 ��_ �Number s <br /> S j ��� <br /> SUMPS Cl Diance to nearest: �—WeII ""4`Foundation Property Line <br /> DISPOSAL P,'OADS Q -- <br /> I hereby certify that I Piave prepared this application and,that the wotk�i�l <br /> will be done accords ce with`§3n(Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health district. i n zYa <br /> Hpme owner or licensed agent's signature certifies the fallowinthat i th�prfornca o �t��wor�t forwhich this permit is issued, I shall not <br /> employ any person in such manner,as to become subiecf•to.workman's-compensation-laws 6-f California" Contractor's hiring or sub-contracting signature <br /> ( certifies the following: h,LI 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 applicant t gr requi r ons. Complete drawing on/rev <br /> sB side. <br /> Signed Date: f ' <br /> 9 <br /> Ii FOR DEPARTMENT USE ONLY <br /> Application Accepted byy2d L, date Z Area <br /> 149-16 <br /> Pit or Grout Inspection by Data Final Inspection by Date + <br /> Additional Comments: <br /> ❑JStk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Pafmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ! ± 3 <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIYNO. <br /> INFO CASH Q�q Q 7 <br /> +.EH 13-24[REV. /x 5] �'� p —'2- �j O �J�� <br /> { EH 14-26 <br /> L th <br />