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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON'AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Job Address1774t) N D61115 _p__ City 1 Loft SizeM <br /> / P/� <br /> F Address 1] / LJ i/� � v i��b 'hone � !�7 Ai <br /> ' Owner's Name <br /> &E-S 7[ t= � /& A SMC 0 ; � License NoQ��Phone - 6����ContractorAddress <br /> TYPE OF WELL UMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C9 OTHER. ❑ - <br /> -' DfSTANCE�TO NEAREST S PfIC`TAh1i< " EWER-LINES' "� DISPOSA0-FLD' "PROP:'t=1NEf <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ix "INTENDED-USE` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial �• ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {-i Public FI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> )N Irrigation _Approx. Depth i I Eastern Surface Seal Installed by RA- <br /> I Repair Work Done ❑ Type of Pump <br /> 'T-up?L f f S H.P. State Work Done co c S C R �` <br /> n Y <br /> Well`Destruction 1710'1 Well Diameter Sealing Material (top 5 U _ Tu' B <br /> Depth Filler Material,(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIRIADDITION l I DESTR CTION I T (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑� Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , <br /> � Distance to nearest: Well Foundation Prope tvoA,g i q a <br /> jr(RECEIVED�� <br /> LEACHING�LINE ❑ No.&,Length of tines - Total length/s'! .r <br /> FILTER BED IJ-- Distance to..nearest: Well Foundation Pro erty Line .._.f <br /> �r <br /> SEEPAGE PITS I lm Depth Size _ Numbdr . <br /> �'1V <br /> UMPSR—Ll—'Distance=to'nearest:-—Well-"��-�-_=- Foundation _ Propert+ _Line <br /> k 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 <br /> rules and regulations of the San Joaquin Local Health District. .. Z. <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 subject to workman's compensation laws of California."Confractor'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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> {R <br /> The applicant must call or all required inspections. Complete drawing on reverse side. <br /> Signed X Y Title: '` Date: 7` <br /> .ii e <br /> FO DEP RTMENT USE ONL t, <br /> -3 Q <br /> cZ 13 <br /> Application Accepted by Date A. <br /> Pit or Grout Inspection by i Date Final Inspection by Date <br /> R <br /> it H <br /> Additional Comments: <br /> ❑ Stk 465-6781 ❑ Lodi 369-3621 E1 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 /> II <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> � INFO n <br /> +.E11 13.24(REV.tin 5) M r / ��e) <br /> EH 14-28 v V <br />