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. I <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 /> j� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete 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. p �I c �r <br /> Job Address Z LcJm Ci "`'� G" Loi Size PM <br /> l K�04_Phone 64 — l� <br /> a <br /> Owner's Name Jam"- Address <br /> Contractor's Nam 4 �✓ '� License No! r Phone 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ '. i-DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 + SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION,i_ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA II CONSTRUCTION SPECIFICATIONS` .j <br /> 13 Industrial ❑ Open Bottom ° i 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ` " _❑ Tracy Type of Casing f Specifications t♦ <br /> ❑ Public ❑ Other El Delta Depth of Grout <br /> % <br /> Seal ' Type of Grout <br /> i `n <br /> ❑ irrigation �.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump H.P., r State Work Done <br /> Well Destruction ❑ Well Diameter 'Sealing.Material (top 50'1 <br /> Depth Filler Material (Below 501 ^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation will serve: Residence 11C4mmercial_/other"� � y � `�,•. y �, <br /> Number of living units: Number of bedrooms 3 ", , to <br /> Character of soil to a depth'of 3 feet: 0 Water table depth <br /> SEPTIC TANK --'.❑ Type/Mfg- eO L s 4'Capacity ��a No. Compartments i <br /> PKG. TREATMENT PLT. ❑ �� '; ' II ` t' /' y Methodof Disposal <br /> Distance to nearest: Well i�a Foundation Property Lin <br /> ,,LEACCHING LINE No. & Length of lines Tota vength/size <br /> FILTER BED f L1 Distance to nearest:- -Well 1! d ^:+ Foundation Z'107 Propertyy L <br /> SEEPAGE PITS Depth -s~ Size 33 i mber a <br /> M1� SUMPS ❑ Distance to nearest: Well l' Foundation /49 Property Line <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 District. ;k - . \ <br /> Home owner or licensed agent's signature certifies the following: "(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.§ubject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the peormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> kThe applicant must call for all:requ'a inspections. Complete drawing on reverse side. <br /> Signed 2 Title: 17" Date: d 11 L p T <br /> i� FOR DEPARTMENT USE ONLY <br /> 4 t <br /> Application Accepted by Date / Area <br /> r <br /> Pit or Grout Inspection by ate Final Inspection by i Date rZ-i��►`�- <br /> 11 <br /> �AaFRtuirn <br /> omments: <br /> 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> ail copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> + EH 13-24(REV.10/83) <br /> EH 1426 <br />