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6 <br /> APPLICATION FOR PERMIT <br /> E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 /> a <br /> Job Address I. 20 h City Lot Size S PM <br /> ' <br /> Owners Name Address !� f� d f �Z�� <br /> j ��' Phone��_7-� <br /> � 030 <br /> H <br /> Contract 1L1i,ta?aI ! lv Address bW?10 License No. 3 z z Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q __9_Ti4ERi ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS It PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ER WELL JPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS UCTION SPECIFICATIONS <br /> ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ! ❑ Domestic/Private ❑ Gravel Pack ❑ Trac ,I T I <br /> y Type of Casing Specifications <br /> M Public ❑ Other -Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigationx.,.ApproDe [ I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of P H.P. State Work Done jt <br /> Well Destruction ❑ Wel rameter Sealing Material (top 50') j <br /> epth Filler Material (Below 50') �l <br /> TYPE OF SEPTIC RK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X Commercial_ Other <br /> Number of living units: --LL Number of br oms .�__ �� 7 <br /> Character of soil to a depthf 3 feet: Water table depth 2--0 <br /> SEPTIC TANK " <br /> Capacity �� � No. Comparti`ments - <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> r Distance to nearest: Well �Q Foundation 10 Property Line Sty 1 <br /> LEACHING LINE 111-"No. & Length of lines 3 Total length/size I sz 61 z <br /> FILTER BED ❑ Distance to nearest: Well 501 Foundation LV _ Property Line �5 <br /> ' l I <br /> SEEPAGE PITS IIT Depth .25 Size �r Number <br /> SUMPS L� Distance to nearest: Well I ov I Foundation IC I Property Line`.__ <br /> DISPOSAL PONDS C] �� y <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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the perforrhance of the work for which this permit is issued, I shall riot <br /> I employ any person in such manner as to become subject to workman's compensation laws of.California." Contractor's hiring or subcontracting 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." v <br /> The appli=ttall required inspections. Complete drawing on reverse side.Signed XJ Title: let.: <br /> r H � 1fi <br /> r FOR DEPARTMENT USE ONLY <br /> F <br /> Application Accepted by Date s �" v. Area <br /> 6i[it 1 <br /> it Grout Inspection by Date ._ Final Inspection by <br /> ateL7� <br /> Z eV <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 2409, Stk., CA 95201FEE I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 4 <br /> ASH RECEIVED BY DATE ! PERMIT NO. <br /> ♦.EH 1324(REV.1/R 51 <br /> EH 14-2a 1 <br />