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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE`T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate? <br /> Application is heieby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. tt <br /> Job Address {� GA Q �� YL[7 > A City o7 Lot Size PM <br /> Owner's Name Address PhoneClaZ <br /> �Contractor, 1f w l 1 Address f Qk 1 �->?/ V License Nv.19Lq'la Phone <br /> TYPE OF WELL/PUMP: "' NEWWELL,)iia,,„ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM FiEPAI `O -` ~r _OTHER <br /> P- ! _ <br /> DISTANCE TO NEAREST: SEPTIC TANK J_']5 SEWER LINES DISPOSAL FLD.I� PROP. LINE <br /> _ FOUNDATION AGRICULTURE WELL OTHER WELL vZ� PITS/SUMPS '-�U <br /> INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r (1 <br /> ❑ Industrial *Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -S�!Ce I Specifications <br /> r <br /> Fl Public. 0 Othyr ❑ Delta Depth of Grout Seal Type l f Grout( 0�M <br /> Irrigation rj-�pprox. depth I 1 Eastern -4', Surface Seal_Installed by-b <br /> Re eu V47ork D'ane"❑ '-7-s af`Pum <br /> -YState'Work-Done_�--"-----H � <br /> ,.Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth _ - ,Filler Material IBelow 501 <br /> � TYPE OF SEPTIC WORK: NEW INSTALLATION I'] AFFAIR/ADDITION f I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> �,.available Athin'200 feet.) <br /> Installation will serve: Residence—-'Commercia'I"=Other- ! <- '^` .-� "' t3, <br /> Number of living units: Number_of-bedrooms <br /> i Character of soil to a depth of 3 feet: : r �--- --�-�� Water table depth 1 <br /> g SEPTIC TANK ❑ Type/Mfg -- Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ t Method of Disposals <br /> ! 1 <br /> F Distance to nearest: Well Foundation Property Line <br /> µr LEACHING LINE ❑ N;. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> h M <br /> ySEEPAGE PITS I 1 Depth s -� Size T �~ Number <br /> ' SUMPS L Distance to nearest y Well Foundation Property Line , <br /> DISPOSAL PONDS ❑ <br /> 'x <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 I <br /> i 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 S <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--rn-t call fall re u r'd`inspectidns.-CO-Molete drawing on teverse side"--"-- <br /> Signed _ Title: rP - Date: LJ <br /> t F R DEPARTMENT USE ONLY <br /> Application Accepted byQ -a, �c�j 1 <br /> Date 4 Area ! <br /> I 1 <br /> Pit or Grout Inspection by DGte 1 Final Inspection by Date J <br /> 41 <br /> Additional Comments: ePO <br /> 3 <br /> ❑ Stk :466-6781 ❑ Lodi 369-3 1 ❑ Manteca W-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 INFO AMOUNT DUE AMOUNT REMITTED CK CA$H1 RECEIVED BY DATE PERMIT'NO. <br /> +.EH121rREV.t/y51 <br /> EH 10-4-2r3 1 <br /> 0 4c>— "T <br />