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.:f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> li Telephone (209) 466-6781 <br /> d PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� (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 /> Local Health District. <br /> Job Address 41' City AlAA17'ZrfA Lot Size /3 AC -- PM <br /> Owner's Name /n S _OA Address Phone <br /> Contractor �Lvyp W00.7 Address License No. G 'Phonetcf-J 9 71 <br /> TYPE OF WE NEW WELL D 'WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> II PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> jI FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS _ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ^� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i`1 Public N f} Other n Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation 1� _.-Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done— <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 <br /> I <br /> �p <br /> n Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION i-I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ,I available within 200 feet.) <br /> ly <br /> Installation`will serve: Residence_tf!f"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 ❑ - Type/Mfg Capacity I z-v o No. Compartments -L— <br /> PKG. <br /> PKG. TREATMENT PLT. ❑ ! Method-of Disposal <br /> li Distance to nearest: Well ZOZ?4- Foundation 16? Property Line s <br /> I <br /> ti LEACHING LINE No. & Length of lines Total lengthlsize h' <br /> FILTER BED). ❑ Distance to nearest: Well L_7_6 t Foundation /s Property Line / <br /> SEEPAGE PITS 1.1 Depth Size — Number <br /> SUMPS 1i L-i Distance to nearest: Well Foundation 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 Di§trict. <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 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 /> Signed X Title: _��.z2-/�� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Date / Area <br /> Pit or Grout(Inspection by Date Final Inspection by Dat <br /> Additional Comments: <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.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CKCASH RECEIVED BY DATE PERMITINO. <br /> INFO <br /> EH 1428 IREV.�/H sl <br /> II 76� 66 <br /> a.EH 13-24 N� <br />