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I <br /> k APPLICATION FOR PERMIT <br /> w <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 /> I 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 /> lu <br /> Job Addressfy I ,`r °Dh`� --- City Lot Size PM <br /> I Owner's Nam Address <br /> "'1 4 tr_ Phone �9 - U019 <br /> - „ nyAddress Q M V� . Phone. 41 S-1 Q_ License No:_ �Contract <br /> TYPE OF WELL/PUMP" +*< r, -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l <br /> `1 '❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I - 4M_ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> r I'111tigation • Approx. Depth I I Eastern Surface Seal Installed by <br /> .. <br /> ��Repaairr Work,Do e"'D'—Type`of-Pump---- ------ H.P.- State Work Done_ <br /> Well Destruction ❑ well Diameter�t Sealing Material (top 501 <br /> Depth _ er Material (Below 50.11 <br /> TYPE OF-SEPTIC WORK,- NEW-INSTALLATION � FII AIR/ DDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> t <br /> �` -`°' x;�r z(, #� }T'�"• r " f "` available within 200 feet.) <br /> Installatiorf will serve:,, Residende_ Commercial--, gther''� f <br /> NurnbWot living units. f.� Number_ <br /> Character of soil to a depth of 3 feet: Water table depth 00 <br /> SEPTIC TANK _ >< Type/Mfg Capacity/i&O No. Compartments 3 <br /> PKG. TREATMENT PLT. ❑ y Method of Disposal _ <br /> •o Distance to near t: `Wei _ Foundation _ Property Line ��A <br /> LEACHING LINE No. Length-of-line: Total"- ®' Total length/size X <br /> z <br /> FILTER BED ❑ Distance to nearest: Well Foundation_. � Property Line .S <br /> SEEPAGE PITS----.�- -Depth- - Size- _ Number �-+ <br /> SUMPS Ll Distance to nearest:` Well Foundation. Property Line __v5- <br /> DISPOSAL POND _-,-❑-_--.. _ _ _ _ '� ' ' __� __�. __, <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, an <br /> rules and regulations of the San Joaquin Local Health D�trict. <br /> Home owne'r 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." Contractor'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, i shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 9 The applicant u call for al uir d inspections. Complete drawing on reverse side. t <br /> Signed X Title: V <br /> i FOR DEPARTMENT USE ONLY <br /> I Application Accepted by Date 6- Area-/ 2- <br /> r it r Grout Inspection by Dates 1�=( Final inspection by Date '- <br /> I <br /> Additional Comments: <br /> ❑ Silk 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 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. <br /> +,EH 1 -24IREV.tirs5l <br /> ' EH 144-28 _1 �_1 `^a ► UU <br />