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� y APPLICATION FOR PERMIT <br /> }' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telepho6e (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> < Application is he+eby 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. <br /> ' Job Address <br /> �7/LJ 7 JL ,04nj City Lot Size f M <br /> E Owner's Name <br /> 7"J.�e . ,erAddress Phone <br /> Contractor �f� S Address L-.CeLicense No._1YSIZ- L Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ =RLOTHE ❑ <br /> l <br /> 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL--. PITS/SUMPS <br /> } INTENDED USE :TYPE OF WELL PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS <br /> ��.._.. Y <br /> I' ❑ Industrial ❑ Open Bottom o Manteca' . 13ia:-oi Weil Excavation �Oia. of Well Casing <br /> [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`1 Public, I❑ Other Cl Delta Depth of Grout Seal t Type of rout . <br /> I. I I Irrigation -�..Approx. Depth i I Eastern Surface Seal Installed by - <br /> _ € <br /> `# Repair Work Done ❑ Type of Pump H.P. State Work Done f� <br /> Well Destruction Well Diameter _/ _ Sealing Material (top <br /> Depth Z-$ Filler Material (Below 5f]') �Z <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DE5 RUCTION I 1 (No' <br /> "septic system permitted if public sewer is <br /> t� �'•l al able within' <br /> 200 feet.I <br /> i Installation will serve: Residence— Commercial— Other}�~_�c-:_- '1 f ! <br /> l Number of living units: Number of bedrooms "-. �' <br /> Character of soil to a depth of 3 feet: <br /> �� '\ Water table depth ` ' <br /> SEPTIC TANK. ❑ Type/Mfg Capacity <br /> No. Compartments �4�' <br /> .I, . <br /> PKC. TREATMENT PLT. ElMethod of Disposa <br /> } i <br /> I l Distance to nearest: Well Foundation Property Line 'd <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' f 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Properly Line <br /> i <br /> r SEEPAGE PITS I'] Depth Size Number <br /> i <br /> SUMPS Li Distance to nearest: Well Foundation Property Line <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 performance of the work for which this permit is issued, f shall not <br /> ' <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 for which this permit is issued,I shall employ psons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant r I requ' pections. Complete drawing on rave ,,side. <br /> Signed K Title: <br /> Ij <br /> FOR DEPARTMENT USE ONLY <br /> al <br /> ate <br /> Application Accepted by _� d , # < Area <br /> _ 1 t i <br /> r <br /> Pit or Grout inspection by Date Final Inspection by �- ? � I Data /vY-$Y. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _2� I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stkf, CA 95201 <br /> t � 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE {PERMIT ND. <br /> INFO <br /> +�EH 13-24 IAEV.1/n 51 I •— <br />