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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> A/V\0 Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iComplete 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 !�gkO 9 /50/" '� City 5 2reV� Lot Size PM <br /> Owner's Name tiAtAC f 5-A GDY-�—L('/ Address 5LAW f Phone <br /> Contractor_ jrLu y1� .er.._f,LJpz/3J Address 7.J, AAE_LBE,�T License No. 417 Phone!�_4_: <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION n <br /> PUMP INSTAL ON ❑ SYSTEM REPAIR Cl OTHER ❑ <br /> DISTANCE TO NEAR ESTTSEPTIC TANK SEINER LINES �- DISPOSAL'FL"D: PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTI PECIFICATlONS <br /> t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack %: ❑ Trac Type Casing Specifications <br /> F]1 Public Cl Other Delta Depth of G t Seal Type of Grout <br /> �- <br /> I I Irrigation _-Approx. th l f Eastern Surface real Inst d by _ <br /> Repair Work Done ❑ Type of mp ~'H.P. nkat, Work Done_ <br /> Well Destruction ❑ Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION X DESTRUCTION i I (No septic system permitted if public sewer is <br /> �s f 1. ' t available within 200 feet.) <br /> Installatin will serve: Residence Commercial Other <br /> Number of living units: _4__ Number of bedrooms Z. <br /> 'Character of soil to a depth of 3 feet: C = .Water.table-depth <br /> SEPTIC TANK ❑ Type/Mfg-­—CEX – r.7 "Capacity" No. Compartments <br /> PKG. TREATMENT PLT, ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation ' �* Property Line <br /> LEACHING LINE IES No. & Length of lines I 4!0 ' - _ _ Notal length/size 4U `X Z ' <br /> FILTER HED ❑ Distance to nearest: r Well 70�z �Foundation .Z 5 ' ,Property Line Z47 <br /> SEEPAGE PITS { i Depth L'S r Size A E` Number A- <br /> SUMPS 0 Distance to nearest: Well i 00 ` Foundation 30' Property Line =5_1 � <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 Diltrict, <br /> Home owner or licensed agent's signature certifies the following: y Pe , -' T'T' <br /> g g g: "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 far.which this permiris issued, 1 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.X4 Title: <br /> _ Date: 2- <br /> FOR <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Z Area Ott <br /> Pit or Grout Inspection b Date Final Inspection by , Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 • ❑ 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 AMOUNT REMITTED CK 41 RECEIVED BY DATE PERMIT'NO. <br /> +.EH1 -241REV.tix53 0� <br /> EH 144-2e � (?Q� 1C''i1 <br /> � !! v {x� <br />