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f <br /> t - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I I (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 G City Lot Size PM <br /> PM <br /> Owner's Name F-D A xlldi C6C� Address it_9-4( �� "( V/ - AWPhone <br /> Co ntfactor C.<1d_GlI I 1 License No. Phone <br /> TYPE OF WELL/PUMP: �NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE <br /> "" FOUNDATION ' "rte AGRICULTURE WELL <br /> ;OTHER'WELL --PITS/SUMPS='r'�`-- " "" a <br /> ,INTENDED USE TYPE OF WELL PROBLEM AREA MCONSTRUCTION SPECIFICATIONS, s <br /> ❑;Industrial ❑ Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> '04-Domestic/Private - ' Gravel Pack D Tracy Type of Casing RoAr Afd AZIOSi)ecifications <br /> ` 0 FI!Public ❑ Other • ii I.Delta Depth of Grout Seal Type of Grout <br /> I I'lrrigation _.Approx. Depth.; l� .,Eastern fit_-,_Surfacp_Seal Ins_tailed by _ 9 <br /> Repair Work Done L1 Type of Pump s H.i517- State WorkDone <br /> a Well Destruction ❑ Well Diameter Scaling"Material {top 501 <br /> Depth �M f=iller Material Telow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I'i, DESTRUCTION l-I (No septic system permitted if public sewer is rf S <br /> 1 -— `t av rlabt-'t OO feet.) <br /> r installation will serve: Residence_ Commercial_ Other a: _'"� �I � 1'�le ) 1 5 <br /> 1 Number of living units: Number of bedrooms <br /> r Character of soil to a depth of 3 feet: r e Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t Capacity__._—_, ` 161J,i4 `)O. ( ments <br /> PKG.TREATMENT PLT. L1 ; Method_ isposal r ' <br /> ( Distance to nearest: Well Foundation sq a Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to_nearest: Well Foundation Property Line r <br /> SEEPAGE PITS 1 1, Depth t Size ^^ _ Y Number <br /> - -. _ <br /> DISPOSAL PONDS ❑ <br /> SUMPS y Ll Distance to nearest:. Well Foundation Proerty Line <br /> p <br /> I hereby certify that I have prepared this applicationand 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 Heaith Di1trict. <br /> 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 as.�to become sulbject to workman's cornpensa`tion laws of California." Contractor's hiring-oi sub-contracting signature <br /> certifies the followd"Iify that rn the performance of the-work for whichthis permit is issued, I shall employ personssubject to workman's compensa- <br /> tior!laws of CalifIThe applican ll req r d ins ons. Complete drawing on r rse side. <br /> Signed X Title: Date: <br /> 1 OR-DEP TMENT USE ONLY 1 z <br /> t <br /> Application Accepted by Date ✓ Area {� <br /> Pit or Grout Inspection by Date Z Final Inspection by f Date <br /> € Additional ComAen 9` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 •❑ Tracy 635-6385 <br /> Applicant - Return all copies to- Environmental Health.Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �/ylfP CCI c �L ���ii! f X. <br /> 1 FEE AMOUNT DUE AMOUNT REMITTED r� CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH 13-24(REV. <br /> EH 14-26 ,x' <br />