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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6 <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"desc►ibed. This application is <br /> made in compliance with'San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address _�[f � Weems/ µ / } <br /> - City �O GI i`. Lot Size Aply <br /> Owner's Name �Protlls f.Lo Address *b"a <br /> Phone - <br /> Contractor /i Sa Address p O. 8o iC 110 pCIP f \ I f r { <br /> O License No. `� $�/ Phone I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIR ❑ _ __ OTHER ElDISTANCE TO NEAREST:'SEPTIC TANk_— — _SEWER'LINES _ �"' "= DISPOSAL FCD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL i PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, <br /> ❑ Industrial ❑ Open Boitom% ❑ Mariteca ,4141%"D,ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public El Other 71 Delta Depth of Grout Seal Type of Grout <br /> Q Irrigation ---Approx. Depth Q Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑. Well Diameter Sealing Material Itop 50') r-- <br /> j Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-N" REPAIR/ADDITION"- DESTRUCTION ❑ (No septic systemR permined if public sewer is <br /> available within 200 feet.) <br /> Installation will serve ..Residence <br /> _ L Commercial Other i 7 <br /> Number of living units: _I Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: Water table depth 30 <br /> SEPTIC TANK ® Type/Mfg Joyo CArT Capacity O 0 No. Compartments J% <br /> PKG. TREATMENT PLT. Q %!,I\------� --- �� <br /> r + Method of Disposal <br /> Distarc to nearest: Vtlell 'a"-� '"Foundation" g a �'" Property Line 7! <br /> LEACHING LINE No. & Length of lines a LO`f + <br /> Total length/size '"'aP �� <br /> FiLTER BED,,r ❑ Distance to neaiest: Well Foundation Property Line i <br /> i <br /> ySEEPAGE PITS ❑ Depth l Size 1D Number i <br /> f, -SUMPS $1 Distance to nearest: Well 24" Foundation J_ A _ Property Line t <br />�iw t DISPOSAL PONDS O <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. I <br /> Home owner or licensed agent's signature certifies the following: "i certify thatr.in the performance of the work for which this permit is issued, I shall not 4 <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 must call for all required inspections. Complete drawing on reverse side. <br /> Y <br /> Signed Title: Date: 3-3 8 <br /> FO DEPARTMENT USE ONLY q4 / <br /> Application Accepted bLbY :,,. <br /> Date /?hg4rea <br /> Pit or Grout Inspection ate Final inspection by �--- Date s <br /> Additional Comments: t2h <br /> ❑ Stk 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.0 ox.2009, 5tk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> +EH 13-24(REV.1/8 51 <br /> EH 14-26 �� BVS/ <br />