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9 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT � <br /> 1601 E. HAZEL T ON'AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> s <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 h 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 City Lot Size M X r f M <br /> Owner's Name H�y� Address SA M#L __ Phone +� S3 to <br /> Contractor �-IMI C^IRCO+C •a o Lgtsiu.i3 24&1,411V <br /> Address � License No. % Phone_,��3��4 T <br /> j� t7YPE OF WELL/PUMf;:,,r NEW WELL ❑ WELL REPLACEMENT EI DESTRUCTION ❑ ,f <br /> tt <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP$ _ <br /> INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J'~ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private ❑ Gravel Packl ❑ Tracy Type of Casing Specifications <br /> M Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation --Approx. Depth I I Eastern Surface Seal installed by �Q <br /> Repair Work Done O Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ` Sealing Material (top 50') l <br /> Depth I Filler Material (BeEow 50'1 r V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION [ DE=STRUCTION i I Wo septic system permitted if public sewer is <br /> { available within 200 feet.) <br /> Installation will serve: Residence!Commercial— Other h - - f <br /> Number of living units: Number of bedrooms <br /> t <br /> Character of soil to a depth of 3 feet: <br /> Watertable depth <br /> SEPTIC TANK ❑ Type/Mfg € Capacity ` No Compartments <br /> PKG. TREATMENT PLT. ❑ # Method'of Disposal <br /> € Distance to nearest: Well Foundation I Property Line <br /> r t � <br /> LEACHING LINE 0 No. & Length of lines � Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Liner <br /> If <br /> E t <br /> SEEPAGE PITS I I Dapth ; i Size� � K lb Nu mber <br /> SUMPS Distance to nearest;;. Well S _ ,Foundation © Property Une} <br /> DISPOSAL PONDS ❑ j <br /> I hereby certify that E 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. s <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work foAvhich 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 foi�vhich this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California'. i t <br /> t <br /> The applicant mu all for all required-iris .tions.-Complete-drawing!on reverse side. dy <br /> I ci <br /> Signed X ' � _ Title: e r <br /> i <br /> F.O,R DEPARTMENT USE ONLY:'`" <br /> Application Accepted by f*1 ? �a- tE <br /> € Date <br /> Pit or Grout Inspection by k� rl ,YJ Date #I I <br /> Final Inspection by S Date <br /> Additional Comments:i i � � <br /> 11Stk 466-6781 11 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> _Applicant_,_Retucn alt.copimtowEnvironmehtal,Health,Permit/_Services 1601_E...Hazelton,Ave.,_P:O._Box_2009;Stk:;..CA-95201 <br /> _ INFO FEE AMOUNT DUE- AMOUNT REMITTED CKAJF <br /> N RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13-24(REV.1/H 51 �/J O <br /> EH 14-2e <br /> } <br />