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APPLICATION FOR PERMIT <br /> GO / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �3 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ,,- (Complete in Triplicate) <br /> aquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Jo <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 /> / <br /> City Lot Size �C PM <br /> Job Address ', Q <br /> Owner's Name <br /> 7►/1�.i��sw+� /�O K L Address — Phone <br /> +`�C� y-=e ria��rt_ <br /> Contractor � <br /> �/ 4r' Address 1 License NoJ 3ww?> Ph <br /> & one <br /> 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR CO "OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. r PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 1OTHER WELL PITS/SUMPS <br /> ."....,INTENDED-USE ,".._TYPE-OF:WELL -'"PROBL-EWAREA—CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> El Industrial El Open Bottom ❑ Manteca Dia of Well Excavation 5 <br /> 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications <br /> Tracy T e of Grout <br /> — <br /> {1 Public ❑ Other Ll Delta Depth of Grout Seal yP <br /> { I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> I ! Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth <br /> Filler Material ISelow 501 -- - -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l i DESTRUCTION I } available within 200 feet.)septic'system permitted if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: --/._ Number of bedrooms _ <br /> Water table depth <br /> Character of soil to a depth of 3 feet: d <br /> SEPTIC TANK ❑ Type1Mfg Capacity_.e.Z19e__ No. Compartments = <br /> *'t <br /> PKG. TREATMENT PLT. O � � 40 Method of Disp9,al <br /> Distance to nearest: Well Foundation 1Property Line�d <br /> i <br /> d 40 <br /> LEACHING LINE � No. & Length of lines — � Teal length/size <br /> FILTER BED [I Distance to nearest: Well 1:0 Foundation/e �' Property Line <br /> t r l <br /> SEEPAGE PITS ) Depth Size Number <br /> SUMPS Ll Distance to nearest: Welle� Foundation. — Prop tirtY Line ! <br /> DISPOSAL PONDS r CJ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou my ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health"Di§trict. ' <br /> Home owner or licensed agent's signature certifies-the following:,) 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 /> l 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." _ _ L. . -+ <br /> The applicant t call for required pectians. Complete drawing on raver a side. <br /> t�F".�._..._..�.. Title: j Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by <br /> t Pit or Grout Inspection by � Fin <br /> Date - al Inspection-by- , Date <br /> 4 a <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOAMOUNT REMITTED UNT DUE CASH <br /> ♦.EH 13.241REV.1/85) 7e �+ Y <br /> EH 14-2a <br />