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V� RL R W, <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1,F1,A R 2387 <br /> L <br /> .1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ENVIROViENTAL,.HEALTH <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT'/SERVICES <br /> (Complete in Triplicate} Y. <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 /> maderin compliance With San Joaquin County Ordinance No.549 for sewage or No..1862 for well/pump and the Rules and Regulations of the San Jo.aquin <br /> Local Health District.to''- <br /> "A L,t;Si., PM— <br /> JobAddress city <br /> Phone-. <br /> Owners Name Addre <br /> 564ie-- <br /> Contractor's Name e— License No. s-7 (11 Phone <br /> —P El <br /> TYPE—0F WELL/ UMP: NEW WELL WELL REPLACEMENT M <br /> PUMP INSTALLATION LJ i SYSTEM REPAIR;tdDESTRUCTION ❑n❑ <br /> El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _'DISPOSAL FLD.-- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL -- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial Open Bottom C Manteca -Dia. of Well Excavation Dia.Specof Well Casing ifications <br /> Domestic/Private E Gravel Pack El Tracy Type of Casing <br /> El Public. D Other 1 13 Delta Depth of Grout Seal Type of Grout <br /> D Irrigation ---Approx. Depth 171 Eastern d �urface Seal Installed by-- <br /> H.P. State Work Done <br /> Repair Work Done D Type of Pump <br /> Well destruction Ll Well Diameter Sealing Material Itop 501 <br /> Depth 'Filler Material i Below 501 <br /> public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION El DESTRUCTION 0 JNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK e 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMFNT±PLT. ❑ Method of Disposal <br /> 71 <br /> Distance to nearest: Well Foundation, Property Line <br /> LEACHING LINE 0 :No. & Length of lines Total length/size <br /> " ,FILTER'Btt) -Distance to nearest: Well Foundation 'Property Line <br /> ,SEEPAGE PITS k 0. Depth Size Number-� - <br /> -;SUMP`­S --&�-.,..r,;-- ❑0 -.Distance to'nearest: Foundation Property Line <br /> DISPOSAL PONDS -­­ -4- 1 1 —. . I <br /> .1 hereby certify that llhav�e prepared this application and that the work Will b4'done in accordance with San Joaquin county ordinances, state laws, and <br /> tuleg and regulations of the San Joaquin Local Health Dlstrict. W'� -- . %-1 <br /> Horne cnwrfer-or licensed�agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> -contracting signature <br /> such"manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub <br /> employ any person in suc <br /> a 2 issued, I shall employ persons subject to workman's compensa- <br /> certifies the following: "I ce that in the performance of the work for which this Permit is <br /> ff i". <br /> a�o or �pel <br /> tio 0 <br /> n1aws of Cilifornia:" <br /> t equir 1 <br /> t mus , I ions. Complete drawing on reverse side. <br /> The appli�ant must�c r equir <br /> 1 7;Title Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Date //-, F7 <br /> sPit or Grout Inspection by tL11A Date Final Inspection by <br /> Additional Comments: <br /> 0 Stk 466-Ml 0 Lodi 369-3621 C1-Manteca 823-7104 = -0 Tracy 835-6385 !. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 Stk. CA 95201 <br /> .I - . . - I . - 4. 1 . A. <br /> k I I _ i <br /> TTED LA;F IR M:11 T�'N 0]. <br /> . . .FEE AMOUNT DUE' : AMOUN T REMI RECEIVED BY DATE P ECASH <br /> '.INFO' <br /> L EH 13-24 iREV.1U1a31. <br />