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q APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOGKTON, CA <br /> 'Telephone (209) 466-6781 ,p s <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)+. _ b <br /> Joaquin Local Health District for permit to construct and/or install the work herein describ . This application is <br /> Application is hereby made to the San Joaq <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. f <br /> Job Address !tif• � A f !.y c3 �P :b City— �. Lot Size ` PM <br /> Owner's NameR64 117 4 Address rAg aV Phone / 643 <br /> ^ - Q�{ ContPhone { szractor D <br />` TYPE OF WEL UMP: !I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION ❑. . ` YSTEM�iEAIR-� _ OTHER_Q_ - _ <br /> - a <br /> DISTANCE TO NEAREST: '' TIC TANK SEWER LINES D "+� PROP�fff�� <br /> FOUN ON AGRICULTURE WEL OTHER WEL ` ` PIT /Sl7MPS� <br /> r INTENDED USE . HYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS <br /> EJ Industrial ❑:Open Bottom ca - Dia. of Well Excavation Dia. of Well Casing <br /> F IID Domestic/Private F1 Gravel Pei Tracy pe of Casing Specifications <br /> ❑ Public ❑ r © Delta Depth o t Seal Type of Grou - <br /> r ❑ Irrigation : Approz�epth ❑ Eastern Surface Seal Insta e - I <br /> Repair W one ❑ Tye of Pum%px H.P. State one— <br /> Well Destruction ❑ We I Diameter. Seaiin Material (top 50'1 --- <br /> 4 to ,a4:ifs,.ier•w...-H.. sem..,? ,,,, K-,�-..—...-*►-� _ ... - ._-._:.. <br /> Depth �Filier Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f❑ REPAIR/ADDITION ❑ DESTRUCTION; iNo septic system permitted if ubli sewer is <br /> available within 200 feet.) <br /> Installation will serve: Resience— Comm e tial Other <br /> Number of living units � Number of bedrooms <br /> : Character of soil to a depth�of 3 feet: Water table depth rr <br /> ASEPTIC TANK ❑ Type/Mfg Capac_ No:Compartments <br /> I,/ 4 <br /> PKG. TREATMENT PLT. ❑ Disposal <br /> Method of Di oral j <br /> Ali <br /> pistance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ IiNo. & Length of lines r Total length/size t <br /> 0 FILTER BED ❑ istance to nearest: Well Foundation Property Line <br /> i <br /> XSEEPAGE PITS ❑ Pepth ' - Sire - N=W <br /> SUMPS El-,]Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑, h t <br /> Phereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawfssrand <br /> rules and regulations of the San Joaquin Local Health District. - .wiT <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work forhich this permit is issued, I shizot <br /> employ any person in such m-fnner as to become subject to workman's compensationlawsof California."Contract' hiring or sub-contracting signature <br /> certifies the following:"I ceAify thin toe performance oft 'wo�ktfor which'this permit is is'kued, I shall employ le ns subject to workman's compensa <br /> tion laws of California." _ +P * � `'+ w <br /> The applicant must call for all required inspections. Complete drawing on reverse side. - <br /> d� <br /> Signed X &" �/ � Title:, bate: <br /> OR PARTMENT USE ONLY <br /> Application Accepted by III DateArea <br /> Pit or Grout Inspection by IiI Date Final Inspection by <br /> D*at <br /> Additional Comments: 1 <br /> El Stk 466-6781 _ ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ TrAcy, 9_!63 %I <br /> Applicant.Return}all-copie "Eh�i�lltalt ermit/Services 160 Hazelton Ave., P.O. Box Stk.,CC5201" <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH 14-28 + CASH <br /> L` <br /> + EH-f3-24IREV.t/Hr -� ` ©� / /Q g7--9clI <br /> J F u <br />