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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 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 /> Job Address 1700 1 Zir}7'fzzD/O Se ?d- _ _ City Lot Size PM <br /> + N � <br /> Owner's Nam,,?7-SF/�G�/a 5�igu CSA R1�� dress <br /> Contractor' dress n- Lit)_ License No.d�"C 9�, Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 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 Weil Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> DepthFiller Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION © DESTRUCTION ❑ (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 bedr oms <br /> Character of soil to a depth of 3 feet: C__ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �Capacity�-�� No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ILf <br /> LEACHING LINE No. & Length of lines _ 7�� /Ls Total length/size <br /> FILTER BED El Distance to nearest: well v�Foundation. Property Lire <br /> /pd' <br /> SEEPAGE PITS ❑ Depth to Size Number ' <br /> SUMPS Distance to nearest: Well uFoundation Property Line <br /> DISPOSAL PONDS ❑ (1J <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: "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 /> The applicant st call for all required inspections. Complete drawing on re rse side.,79 <br /> Signed X Title: zzel bate: �/ g� <br /> DEPARTMENT USE ONLY � <br /> Application Accepted by Date _ Area 6(1::) <br /> Pit or Grout Inspection by Date Final Inspection by e91Datep <br /> Additional Comments: <br /> ❑ Stk 4W6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO �1 CASH J/� f �1 p! i /� <br /> + EH 13-24{REV.iie51 7d . U� 1 ?b3Y- IVU <br /> /l 'f! u 6 QYJ_{yyy <br /> EH 14.26 ��rl <br /> f <br />