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APPLICATION FOR PERMIT <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 /> (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 /> Jab Address /' Cit Lot Siz,.AcAgA,,nte PM <br /> Owner's Name Address "'� L 7� ��! e& � Phone <br /> r /J <br /> {Contract t Cd Address PQ�� 7 7 ZZ License No. : ,2 Z Z6 . Phone <br /> TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ -DESTRUCTION-C-`­,1 _/ a <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f OTfiEFi..Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- DISPOSAL FLD. PROP. L--INE v <br /> FOUNDATION AGRICULTURE WELOTHER WELL : "PITS/-SAPI S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `Dia,#of-WeIr,.Ca'sing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ► ! I Irrigation v.Approx, Depth l I Eastern Surface Seal Installed by _ (, <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done-_--'x.- r <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material /Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted`iLpublic sewer is <br /> available within 200Aeet4--=- %_..,-' <br /> tl Installation will serve: Residence 6� Commercial_ Other <br /> Number of living units: J__ Number of d oms - {� <br /> Character of soil to a depth of 3 feet: Water table depth; <br /> SEPTIC TANK Type/Mfg Capadity 16®O No. Compartments <br /> PKG. TREATMENT PLT.'❑ i t Method of D�posal <br /> f r Distance to nearest: Well..C:�45-_-_._ Foundation Property Line _ <br /> LEACHING LINE �9( No. & Length of lines Total length/size IRO X <br /> FILTER BED ❑ Distance to nearest: Well Foundation Ptope. Lineot JF ---t� <br /> c� I <br /> SEEPAGE PITS Y4 Depth Size Number - <br /> SUMPS Ll Distance to nearest: Well .1�6 Foundation Property Line _ <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 4 <br /> rules-arid regulations of the San Joaquin Local Health District. <br /> Homeowner 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 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."' <br /> The applicant mus all for all Fred inspections. Complete drawing on reverse s d <br /> Signed X - Titre: 'f �/.p Date: 041 <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Datf--7/_ _ Area <br /> { H� O <br /> rt r Grout Inspection by Final Inspection by <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO �j CASH <br /> a.EH 13-24 IREV. <br /> EH 14-26 /` <br />