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APPLICATION FOR PERMIT <br /> o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 NO <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) lVq ta,Lt� O/pIrica <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. T!hisation is <br /> made in compliance with San Joaquin County Ordinance No.548 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_ 6QW, -0 PM <br /> Owner's Name, 1>w A9 a, gE�7d. ' Address ~ Phone <br /> Contractor---A 1-1, iS446ne—Address P.Ok /490r:F License No4 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of WVA Excavation, . Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT16N•11 'REPAIR/ADDITION l 1 DESTRUCTIOP'SeNo septic system permitted if public sewer is } <br /> available within 200 feet.I <br /> Installation will serve: Residence— (Commercial_-Other <br /> Number of living units: Number of bedrooms - -1`• ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Lengthof linesT Total length/size 9 <br /> FILTER BED ❑ Distance to rsearest: Well Foundation 'Property Line lP <br /> SEEPAGE PITS I I Depth Size Number f <br /> SUMPS Ll Distance to nearest: Well Foundation 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. <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 /> employ any person in such manner as to become subject to workman's compensation laws of California.''Contractors 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call fo II r quired inspections. Complete drawing on-reverse side <br /> Signed X —T��iAi Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by _ g Aa w..�- Date ��� Area <br /> �r <br /> Pit or Grout Inspection by _ Date Final Inspection by Date <br /> Additional Comments: �0 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 ❑ Tracy 835-6385 s' S_ �p q y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> CK 4T <br /> itsMOUNT DUE AMOUNT REMITTED CASH RECEIVED.BY DAITE PERMIT'.NO.-- <br /> 141 <br /> EH 3-24 EH Is.29 IREV-a i y 57 .i"f� r,� J ' �� <br />