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APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Tri plica#e) <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. ' its. , w, F,., , .... , r <br /> Job Address City �Sri16+ LaN� Lot Size 64A PM <br /> 41 <br /> Owner's Name 47)M! 199- -:,�1071. Address 2 Sttuy'+^..._.- Phone <br /> Contractor 0 . � -SAA' Address �/�� Arox /ly /+yo s License No. 9"y"09+1 Phone S'073 <br />"""'""'"TYPE-OF WELL/PUMP: NEW WELL 7-1 REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 i <br /> DISTANCE_ 0 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP-,jLINEr -- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS.,_ <br /> k l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS sr <br /> ElIndustria ❑ Open Bottom ❑ Manteca Dia, of":WeIIZx&i ationP�l Dia. of Well Casing <br /> 6 <br /> ❑ Domesti /Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of G'rout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed._by <br /> Repair Work pone C1Type of Pump H=? —State`Wbrk D6N61 <br /> Well.Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material iBel-ow,WU <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION a_REPAIR'/A_'DDITfON�-❑ —DESTRUCTION El {No septic system permitted if public sewer is <br /> �" �' available withim200.feet.: <br /> Installation will serve: Residence Comm ercial_ Other Y <br /> Number of living units: I Number offbedraamS' x ,� <br /> Character of soil to a depth of 3 feet:, Water table depth <br /> SEPTIC TANK ❑ Type/Mfg l Capacity—O No. Compart nts <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1 V <br /> p Distance to nearest: Well �':Foundaton � � Property Line <br /> 1 <br /> LEACHING LINE X No. & Le gth•of-lines �'d Total length/size 5"0 U-1 I { <br /> FILTER BED ❑ Distance o1nea si: Well �'������Foundation �� Property Line 3Dd�� 1 <br /> ;SEEPA6 PITS -❑ Depth i�Size ___ Number' I <br /> �,JSUMPS ;- — - Distance to nearest: Well Foundation 3d� Property Line <br /> L <br /> DISPOSAL PONDS ❑ <br /> 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 perfoFinance of the work for which this p irmit is issued, i' hall not <br /> employ any person in such manner as to become subject to workman's compensation laws 6f California." Contractor's hiring or ilub-contracting signature <br /> certifies the following:"Icertify that in the performance of the work for which this permit is ued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must tali f1r all required inspections. Complete drawing on reverse side. # <br /> Signed Title: Date: i <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by ate Final Inspection by Date 7 �7 <br /> Additional Comments: "� ;•" ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Perrnit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 ;­T :FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO:� i <br /> �+ 4IREJ.1/85 <br /> EH 13-2 �;c s y <br />