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' APPLICATION FOR:PERMIT <br /> SAN JOAQUlN LOCAL HEALTH DISTRICT <br /> y 1601 E. HAZEL T ON:AVE., STOCKTON, CA <br /> �. Telephone (209) 466-6781 <br /> F f r �: J,, <br /> ' PERMIT EXPIRES 7 YEAR FROM DATE ISSUED y. <br /> t. k�. n :_(Complete in Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wok 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 /> GO- <br /> Job Address '!/ 'k*`' �i" ry• Ft"Ft r .� <br /> _. city Lot sae (!� / <br /> PM <br /> Owner's Name <br /> �-� oneas <br /> I <br /> Contractor's Name `� 9[�J Liconse Noyfj� FYPE OF,WELL/PUMP: ' NEW WELL ❑ DESTRUCTION Ohone <br /> f � WELL'REPLACEM <br /> t ml PUMP INSTALLATIO-W❑ SYSTEMREPAIR ❑ <br /> y,}, , OTHER El.�C►ISTANCE TO NEAAE57; SF'PT1C TANK SEWER LINES i <br /> DISPOSAL FLD. PROP. LINE <br /> •� . FOUNDATION 4 <br /> ,: j 7 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ` a INTENDED USEY. STYPE OF WELL: PROBLEM AREA . CONSTRUCTION SPECIFICATIONS <br /> ��Iridustrial ❑ Open Bottom; ,❑'.Manteca ; ?S tDia. of Well Excavation <br /> ❑ DomesticlPrivate.,— -❑ Gravel Pack Dia. of Well Casing � <br /> f"� • - f t x :. D Tracy Type of Casing Specifications <br /> }❑_Public ❑ Other `� r-❑ Delta I <br /> � Depth of Grout Seal Type of Grout � 1 <br /> r ❑ irrigation, _Approx. Depth ❑ Eastern" Surface Seal Installed by <br /> Repair Work Done i!El Type of Pump H. A - . <br /> Well Desiruction�" 71 }{Nell Diameter State,Work Done <br /> Sealing Material (top 50'1 " <br /> -Filler Material-(Below 50'} <br /> TYPE OF SEPTIC WORK; NEW INSTALLATIONREPAIR/ADDITION ❑ DES7RUCTlON ❑ (No septic system permitted if public sewer i w { <br /> available within 200 feet.► s 74 <br /> '. Installation will serve: Residence Commercial Other ► <br /> Numbei of living units: Number of bedrooms t <` <br /> Character of soil to a depth of 3 feet: ! �D <br /> SEPTIC TANK Water table depth <br /> Type/Mfg Capacity J No. Compartments <br /> PKG, TREATMENT PLT. ❑ <br /> QIN <br /> '1 �y <br /> Distance to nearest: Well . Method of DisposalFoundation._ 7 V (.] <br /> Property Line p ri ` <br /> k <br /> LEACHING LINE <br /> No. & Length of lines t' �Q Total length/size <br /> FiLTER BED ❑ Distance to nearest: Wel64O 4,i <br /> un r� ' + <br /> § Foundation " Property Line <br /> SI_EPAGEPITS . `Depth tze <br /> \ Number <br /> SUMPS . N; ❑ Distance to nearest: Well !S�09 p) Foundationi f <br /> DISPOSAL PONDS .❑ ✓ - -- Property Line <br /> 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. t _ <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the wok 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 tKe following:"I certify that in the performance of the work for which this permit is i <br /> tion laws.of California." ssued,I shall employ persons subject to workman's compensa- -4 <br /> The applicant most c I r e uir i ctions. Complete awing on re side. <br /> l r <br /> Signed i r 7r Ly <br /> ., Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> �. Date,' ! Area <br /> Pit or Grqut Inspection by at 11) S �� Fina! inspec'on by e#-a <br /> Date <br /> dditional.Comments: <br /> , tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -823-7104 ❑ Trac 5-6385 [ <br /> Applicanti- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box , Stk., CR 95201 <br /> v <br /> { <br /> FEEAMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> _ PERMI?`NO, <br /> +EH 1334(REV.10/83) I i <br /> EH <br />