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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. a ", <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'.•Aull <br /> ] <br /> Job Address r t' �[1 . y(City° ' r Lot Size -PM.. . <br /> Owner's Name jl% � Address >` 7 ! YCO� l y (2 "7 3 f <br /> Contr ct / 4dRIC Address �: (L � _ # �I License fVo- F��Z� Phone &9-s /O <br /> TYPE OF WELL/PUMP~. NEW WELL ❑ WELL REPL`A'CEMENT'❑- DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR. ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---4pprox°Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump __-„ H:f' State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing,Material Itop 501 J <br /> Depth 'ller Material (Below 50) 04 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIR,.ADDITION ©- DESTRUCTION ❑ (No septic system permitted if public sewer is w <br /> available within 200 feet.► <br /> Installation will serve: Residence Commercial I Other` T <br /> Number of living units: Number of b'drooms j r <br /> Character of soil to a depth,of 3 feet: ~ r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 3-+ i Capacity M NoCompartments <br /> PKG. TREATMENT PLT. ❑ v ; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> p�fQ LEACHING LINE ❑ No. & Lengtli of lines _ / !� ' ^ ,Total length/size -X X y t <br /> l r <br /> FILTER BED Cl Distancell Foundation e <br /> ea <br /> to nrst: ' - Wea 7 ' <br /> € -- - � R _ .f C� -Property'Line_ <br /> rr 1 •.. <br /> SEEPAGE PITS ❑ Depth Size f a R f Numbbr <br /> SUMPS ❑ Distance to nearest: Well '= Foundation -1 Property Line <br /> DISPOSAL PONDS ❑ � •�_ �; �j�;�' <br /> I hereby certify that I have prepared this;appiication and that the,work will be done in'accordance_with-San Joaquin county ordinances, state laws, and <br /> r i• <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 performance of the work for which this permit is issued, I shall not <br /> r 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 for which.this-permit•iwissued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> t <br /> The applicant must call for all requir d inspections. Complete drawing on revers-6-si- <br /> Signed X Title: i Date: <br /> f. <br /> FOR ART AEN,T USE-UNL•Y-- <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Data Final Inspection by Date " <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 623-7104 EI Tracy 835-6385 <br /> Applicant—Return all copies to:_Environmental-Health-Permit/Services 1601-E-Hazelton Ave..-P:O-Bax 2009;Stk.�CA 95201-- <br /> ��. - <br /> 711 <br /> FEE AMOUNT DUE=' AMOUNT REMITTED `�X� `CK CASH <br /> INFO L'-RECEIVED BV' DATE PERMIT'Np- <br /> ' <br /> a EH 13-241REV.1/x351 <br /> Els 14-2e • ca �/ -�b "' 75 <br />