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fi <br /> > APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRIf + <br /> 1601 E. HAZEL T ON AVE., STOCKTON, ; <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISgUED <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 /> Local Health District. J i <br /> Job Address-L ss 0 City Lot Size %7? <br /> O PM" <br /> ­ <br /> 99�j ] cry v 9 --;?PL 0 <br /> _ Owner's Name A/tee 1V� /tP(/I��C���Address t '" L// A-) PH Phone 'y <br /> —; <br /> Contract PC'� -� A dress �,(" t��C� License No. SlPhone <br /> WELL/PUMP:r NEW WELL WELL REPLACEMENT`❑- DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑r SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST:SEPTIC TANK - SEWER LINES i DISPOSAL FLO.9SL_ PROP. LINE Q <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ 24 <br /> �Industrial ❑ Open Bottom ❑ Manteca Dia. of Well_Excavation Dia.of Well Casing (�� <br /> 5 <br /> k- omestic/Private M-�favel Pack El Tracy Type of Casing 7t � Specifigatipns j� <br /> i l Public C1 Other i-Y Delta Depth of Grout Seal Type of Grout _ G1 <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done {/ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 L11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other y` <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> -SEPTIC TANK ❑ Type/Mfg Capacity No.,Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal, <br /> Distance to nearest: Well Foundation Property Line <br /> s <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ T Number <br /> SUMPS Ll 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 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 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 ca for all required inspections. Complete drawing on reverse side. <br /> Signed X " Title: X111. /e� Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> A lication Accepted b f:,? 1v� / <br /> pp P Y Date Area ! I <br /> Pit r Gr t Inspection by / Dz:� Final Inspection by Date <br /> Additional Comments: 110J1iTS <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 <br /> INFO AMOUNT DUE AMCIUNT REMITTED CAtW RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24 IREV.1 i x 5) <br /> EH 14-28 O g 1„ <br />