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— .�1. ,V/O 5 a II <br /> APPLICATION FOR PERMIT <br /> SAN JOAO,UIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ON}.AV�., STOCKTON, CA <br /> TelepTi'on� t09}'466-6781 <br /> PERMIT EXPIRES 1 YEAR-PROM DATE ISSUED'f `�' <br /> (Completelin Triplicate). t#t'" f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem descnbed..Tth application is <br /> made in compliance with Sart Joaquin County Ordinance No.549 for sewage or No. 1862 for well/.pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> R. it <br /> t <br /> 5 t,a• ?PCU <br /> "� <br /> c £+ Size <br /> Z0 ; <br /> Job Address . -x_ kr .r <br /> P_Lg D - Phone`� <br /> Owner's Name 10,ddress T ' _ <br /> ZJ� .3Phone <br /> Contractor (A.IM Address x <br /> NE WELL ❑ WELL REPLACEMENT Q DESTRUCTION ' <br /> TYPE OF WELL/PUMP: OTHER Q <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR-❑ ": <br /> ER LINES _ DISPOSAL FLD. PROP!LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK AG CULTURE WELL OTHER WELL PITS/$LIMOS <br /> 3 FOUNDATION <br /> rl <br /> INTENDE,p U)SE; t TYPE OF WELL PROBLEM AREA r. CONSTRUCTION SPECIFICATIONS Dia. of Wel! Casing <br /> F [Iindust it al ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> of Casing Specifications <br /> Q Domestic/Private CJ Gravel Pack [I Tracy Tye Type of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal yp <br /> ❑ Irrigation / ---Ai x. Depth❑ E♦astern Su a Seal Installed by <br /> Q' Type of Pump ! T H.P. State Work Done <br /> Repair Work Done YP <br /> Well Destruction ❑ Well Diameter 'S651ing lVlaateriel <br /> Depth ¢Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ SDDiTION ❑I pESTRIlCTION ❑ lavseptic <br /> ailablewtsystem 0in20feettled if public sewer is <br /> Installation willserve: Residence Commercial a Other <br /> Number of living units: Number of bedrooms ! <br /> Water table depth <br /> Character of soil to a depth of 3 feet: .q� <br /> Capacity No. Compartments !1 <br /> i SEPTIC TANK E] Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well-_ .=.-foundation,..-- Froperty_Line <br /> t <br /> LEACHING LINE ❑ No. & Length of lines 's J 'Total lerigth/size A <br /> FILTER BED E] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth i Size Number <br /> SUMPS ❑ Distance to nearest: ,.'Well Foundation Property Line <br /> t <br /> DISPOSAL PONDS ❑ g.. l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqlaws, and <br /> uin county ordinances, state <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner nt'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 an arson in such ner as to b come ject to orkman's compensation laws of California." Contractor's hiring oLsukro�?racting mature <br /> certifies a followinq.-I cern that in th ce of a work for which this permit is issued,I shall employ persons subje'fes,. vi�4' an's co tpensa- <br /> tion law of California." ( w�, 7 , <br /> The ap icant must c for requ' s. mplete drawing on arse si <br /> l Q�� Date: �; <br /> Signed _ Title: �'"_ � ,it <br /> -�+ r FOR'DEPART NT USE ONLY t t <br /> yy Asea <br /> V' Date <br /> Application Accepted by xr <br /> t r <br /> ate <br /> Pit or Grout Inspection by - F Data Final Inspection by D <br /> Additional Comments: <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Healh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009'Stk., CA 95201 <br /> FEEAMOUNT REMITTED, _—CASH'— <br /> CK# . RECEIVED-BY_,,.,.--+ ...DATE-.,..-PERMIT'NO. <br /> k INF6 "*'AMOUNT DUE., _ CASH"_� ��IA— , , <br /> z 3\ tom. <br /> +EH 13241RE17 t/B5),} :.QO �... <br /> EN 14-26;, <br />