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APPLICATION FOR PERMIT <br /> F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ;t 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> } <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 /> t., Local Health District. ) <br /> Job Addres —_ j City15-tLot Size PM <br /> JJ LA <br /> Owner's Name Lys+ A ti Address Phone <br /> Contractor LeE w PLT �LLAddress. ,5o License No. Phone <br /> TYPE OP—WELL/PUMP: NEW WELL ❑ '" t WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r.,T. <br /> UMP INSTALLATION';❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES 4 DISPOSAL FLD. PROP. LINE <br /> t <br /> FOUNDATION AGRICULTURE WELL'• OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 17 Manteca Dia. of nation 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 t---Surface Seal Installed by <br /> _ Repair Work Done ❑ Type of Pump H.P. `` 1 State Work Done <br /> Well Destruction ❑ Well Diameter ti I `t Sealing Material.fiop 50'1 <br /> _J ,� �� � 'beotfix Filler Material {_Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> � � available within 200 feet.) <br /> Installation will serve: Residence t! Commercial— Other 'r` <br /> Number of living units: Number of bedrooms i a, <br /> Character of soil to a depth of 3 feet: _ 1�� Water table depth <br /> SEPTIC TANK Type/Mfg C)�1 C r"F5'�_._,- w CapacityI l c)-O � No. Compartments <br /> PKG. TREATMENT PLT. ❑ �� Method of Disposal <br /> Distance to nearest:. Wea Fou d tion b Property Line v�V <br /> ) <br /> LEACHING LINE U, No. &"Length of linea cD= -1 Total length/size I 7D <br /> FILTER BED ❑ Distance to nearest: Well #r Foundation t'Z Property Line <br /> SEEPAGE PITS Size 3 Number _ <br /> � <br /> �C��C� e <br /> SUMPS 1-1 Distance to nearest: Well2�_-Foundat Property Line <br /> DISPOSAL PONDS Cl <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. I <br /> Home owner or licensed age signature certifies the follow_ ing:"I certify thatain the performance of the work for which this permit is issued, I shall not <br /> e oy any person in such mannaNstobecome suject'toworkmanSs compensation laws'of'Celifornia."Contractor s hiring orsub-contracting signature <br /> certifi a following: "I certify thperforman of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws o lifornia." <br /> e applicant u all fora drawin on re�rse side. <br /> Signed Date:1 <br /> FOTMENT USE ONLY <br /> ication-Kc cepted-hy Date Area <br /> I Pi <br /> r-Grout Inspection by Date Fi a spection by - �' Date <br /> / __LL�1�4o <br /> ` Additional Comments: O1�J /0! <br /> ❑ Stk 466_-67_81 0 Lodi 369-3621 O MantQo_-823-7104_ _ ❑Tracy-835.6385 <br /> Applicant- Return all capias to�Emironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> <7 r <br /> FEEINFO AMOUNT DUE AMOUNT REMITiE6 r 11 4 CA9HRECEIVED BY DATE PERMIT"NO. <br /> %ay+ EH1&241REV.siesl �'(p�3�O <br /> EH 1428 �` �� <br />