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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C oPY _ 4s 6oILT- <br /> 1601 E. HAZEL TON 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 11 <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 J 'C �� PM <br /> City' Y Lot Size( <br /> Owner's Name - ) 12 j'Pa2 _ Address <br /> —`` <br /> Ph-one-- <br /> Contractor <br /> hone-Contractor / u l+ '4ddres5 , a <br /> TYPE OF.W - License No Phone 41 <br /> -�•'.• "� NE ELL Q.' <br /> WELL REPLACEMENT ❑ DESTRUCTION El <br /> '' PUMP INSTALLATION°O SYSTEM REPAIR ❑ <br /> DISTANCE To NEAREST:-SEPTFC.TANK- OTHER El <br /> LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _f r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 71 In ��[T[ ' <br /> Industrial 15 Bottom ❑ Manteca 1 Dia. of Well Excavation <br /> �'' <br /> ►v <br /> 1/ C1Domestic/Private f-1GravelPack Dia. of Well Casing y <br /> ❑ Tracy Type of Casing { <br /> EJPublic ElOther Specifications <br /> ❑ Delta Depth of Grout Seal Type of.Grout <br /> ❑ Irrigation ,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ t Type of Pump H.P. <br /> State Work Done.- <br /> Well Destruction ❑ -Well Diameter - - - Sealing Material (top 50') <br /> Depth Filler Material (Below 50') 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ AEPAIA/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> '. available within 200 feet.) <br /> Installation will serve: Residence—L--"Commercial—a <br /> - Other,, <br /> Number of living units:1— Number of bedrooms4 <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg l CapacityNo. Compartments <br /> 4KG. TREATMENT PLT. ❑ f Meihod of Disposal <br /> Distance� to nearest: .Well Foundation� ,, r Property Line <br /> LEACHING LINE No. & Length of lines. t3 Total EJlength/size <br /> 'FILTER BED ,' Distance to nearest: `Well ) +Foundatiol _ <br /> r n PropZ Line , <br /> 1 SEEPAGE PITS Depth Size <br /> Nu be t <br /> SUMPS ❑ Distance to nearest: Well Foundation'C x <br /> DISPOSAL PONDS F1 �fPro Line <br /> I I hereby certify that I have prepared this,application and that the work will be done in accordance wittiSan Joaquin county ordinances, state laws, and <br /> rules and regulations of the San,Joiquin Local.Health District. <br /> Home owner or licensed agent'i 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 such4nanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:",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 req 'e i6spectioAs. Complete drawing on reverse side. <br /> Signed ? Title:r- ._J jt ��!? <br /> • Date: <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by Datel <br /> Pit r Grout fns y-Inspection hb C�c��� Area�. <br /> Date,.-5' �'-4� _ <br /> Final Inspection by_('y �� .� �r~Date <br /> Additional Comments: t <br /> O Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6386 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT REMITTEDCK <br /> INFO AMOUNT DUE CASH RECEIVED 8Y DATE PERMIT''NO. <br /> +EH13-24'(REV.t/85) �� �?�j, C• _ _ „� ] Q/ J <br /> EH 1428 <br />