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F <br /> r , <br />' - APPLICA ON FOR PERMIT <br /> SAN JOAQUIN LOLEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> 4: ( (Complete in Triplicate) <br /> t 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 /> I local Health District. <br /> Job Address 21 a(L- City L-I M Lot Size...WPM PM r <br /> f ! _11 ca3Q ��1�'L� Phone 9S "ZZ LI <br /> Owner's Name � '��'" � ` \ t� _ Address - <br /> r ' j \ p <br /> Contractor u 1 \ AddresS E mt License No. 3,5�Cil 4`-,hone 53- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D <br /> DISTANCE TO NEAREST: SEPTIC TANK s SEWER LINES DISPOSAL FLD.'- PROP; LINEM_ <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PIT515UMPS +1 <br /> INTENDED USE TYPE OF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T <br /> ❑ Industrial— - --;—,-❑_Open Bottom ❑ Manteca ' Ria. of Well Excavation Dia. of Well Casing f <br /> :E [71Pa <br /> Domestic/Private ❑ Gravel ck �EI-Tracy 'Type­of Casing Specifications <br /> t'1 PubGc F1 Other ❑ Delta hDepth of-Grout Seal Type of Grout <br /> Approx.-Depth I I Eastern Surface Seal Installed by <br /> I I Irrigation �.-ApP P - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> f Well Destruction D Weil Diameter SealingtMa erial Stop 501 <br /> r- Depth - Filler Material (Below 501 <br /> .4 <br /> TYPE OF SEPTIC-WORK: NEW INSTALLATION REPAIR/ADDITION i-I DESTRUCTION l I (No septic system permitted if public sewer is <br /> r available,within 200 feet.) <br /> Installation will serve: Residence__V-Commerci I Other <br /> Number of living units: Number of bedroo� s_21 <br /> Character of soil to a depth of 3 feet: ,y Water tabledepth <br /> r <br /> ir SEPTIC TANK 6 Type/Mfg Capacity �O �• No.-Compartments <br /> PKG. TREATMENT PLT. ❑ { 8 , 1 Method of Disposal <br /> I Distance to nearest:' Well 'Foundation y il- Property Line ^ <br /> 1 LEACHING LINE N No: & Length of lines 3` bi # � Total length/size <br /> 7 1� <br /> FILTER BED ❑ Distance to nearest: Well 1 cif Foundatio� "PrUpr ty`Line <br /> SEEPAGE PITS W Depth , Size_.._— — Number <br /> i <br /> SUMPS L] Distance to nearest: Well 11004.-. Foundation 55 Property Line <br /> DISPOSAL PONDS ❑ <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 of 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 /> Theapplicant must call for equired i tions. Complete drawing on reverse side. <br /> t Signed X Title: r V Date: _:97 <br /> FDR'DEPARTMENT USE ONLY <br /> ky� <br /> Application Accepted by __ Date .� t��� Area <br /> CPit Grout Inspectio w Date �6- Final Inspection by Date,' 6 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 D Tracy 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> e <br /> FEE <br /> r INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. <br /> 4 <br /> t r/ �l <br /> ♦ EH13-241REV.t/H51 j <br /> EH 14-28 <br /> ,_ A s, �J <br />