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lU;on AM <br /> i 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 /> (Complete in Triplicate) <br /> ti <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 /> { �. 'r PM . <br /> Job Address � �' � Ci Lot Size <br /> Owner's Name - '11 Address Phone 'V-11;-1F �` <br /> ^M -•tom_ ,,.__ ®_ .. _ � _ _ . <br /> g Contractor's Name Ql yf� l .. License No. 6- ' <br /> Phone, <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-0- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES -_� DISPOSAL FLD. PROP. LINE `l <br /> 1, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i , <br /> INTENDED USE\ 5- (TYPE�OF WELL EM AREA C RUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private Ll Gravel Pack r] Tr of Casing Specifications f <br /> -� <br /> l ❑ Public D Other _Delta Depth of Grout Seal Type of Grout <br /> El Irrigation —Approx. Depth ❑ Eastern _ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. �'� !^ . _ State Work Done �[ <br /> r T <br /> Well Destruction ❑ Well Diameter Sealing Material-{top 5�'•1<-� I <br /> Depth Filler Material (Below 50' <br /> TYPESEPTIC WORK. .NEW 1NSTALLATIO REPAIR/ADDITION ❑f DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence--Co(nmercial,,-- Other 1 t <br /> Number of living units: Number of bedro m <br /> Water table <br /> Charaler)of soil to a depth of 3 feet: 6 _ � _ 3-5e depth <br /> SEPTIC TANIS�£ +ceJ� Typal Mfg � dl f7 G _ Capacity �C/ No. Compartments <br /> PKG. TREATMENT PLT ❑ Method of is oral '" <br /> Distance to nearest: Well Foundation Property Line _ <br /> 1 <br /> LEACHING LINE No. ✓3t Length of fines !� �otal length/size <br /> FILTER BED ❑ Distance to nearest: Well_l� Foundation - Property Line--� <br /> r SEEPAGE PITS Depth Size Number i <br /> k SUMPS ❑ d]istarrce to-nearest. 1Well` .Foundation/- <br /> , 06 Property Line !t <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared't�iis�applfcabon and that the wo?R arilN�be done In-"accordance with San Joaquin county ordinances, state laws, and } <br /> rules and regulations of the San,Joaquin-LocalWealth bistrict. P., f <br /> Home owner or ffcensed€agent's sigpature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> f employ any person in su K'hnir asto'.,become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the foil owin "I certffy that in the performance 6f the work for which this permit is to issued, I shall em <br /> p y persons subject to workman's compensa- <br /> E tion-laws of Califor a � g <br /> The applicant m or all red inspections. Coh,plete drawl i;g'on`reverseAl <br /> � t� <br /> l Signed ol Tfle: x.� � Date: <br /> ! F DEPARTMENT USE ONLY <br /> ation Accepted by Date (� V Area <br /> Pit r Grout Inspection by Date 1/�•�� Final Inspection.by T Date 2 ' i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36:38'21 0-Manteca?'823 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 1009, Stk., CA 95WIFEE �� N <br /> fINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> +EHH 2.4 14.25 —70- 00 <br /> V.,o,e31 <br /> R .. <br />