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APPLICATION FOR PERMIT <br /> r 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 /> 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. b f� � <br /> Job Address L!lO � �A/VG O h.Z city CZf tC.A'u + <br /> a Lot Size O PM <br /> Owner's Name S2 p N 4vz C IN Address m Phone-7sC/` <br /> Contractor C120$.S Addresstoo License No.J7'73ti's Phvne�3y <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> F PUMP INSTALLATION�Kd SYSTEM REPAIR © OTHER ❑ �+,.� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS' <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUC IT ON'SPECIFICATIONS -� <br /> ❑ Industrial t Q Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 3'Gravel Pack 0 Tracy Type of Casing ��C Specifications <br /> f l Public fl Other CI Delta Depth of Grout Seal S O Type of Grout_e 1-�wr <br /> I I Irrigation • '3 tom!-Approx. Depth I ) Eastern Surface Seal Installed by CdA/ -eAc.-rat <br /> Repair Work Done ❑ Type of Pump $rJ H,P. a State Work Done <br /> Well Destruction O Well Diameter Sealing-Material (top 501 <br /> Depth I Filter.Matorial (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/AbDITIONI I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other r <br /> Number of living units:' 4 Number of bedrooms f. <br /> Character of sail to a,depth of 3 feet:c Water table depth <br /> SEPTIC TANK Cr', 0 f T <br /> ypelMfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT-,. L11. Method of Disposal <br /> Distance to nearest: Well ��.'1 Foundation Property.Line <br /> LEACHING LINE 0, No. & Length of lines r Total length/size <br /> 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ! I I Depth Size w+ F Number <br /> 3� <br /> SUMPS El 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. I i ,� <br /> Home owner or licensed agent's signature certifies the following: t <br /> g g g: "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`Calif_6mia'" Contractor's hiring or-sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permits issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." { <br /> The applicant must call for all required inspections. Complete drawing ori,reverse side. stij ' <br /> Signed >L r Title: _07t� _ Date: <br /> s FOR TME yT fVLY - <br /> " 4 Application Accepted by pate li Area <br /> Pit or Grout inspection by Date Final Insp`action by- Date <br /> Additional Comments: (� <br /> ❑ Stk 466-6781 Q Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEINFO AMOUNT DUE € AMOUNT REMITTED ASH RECEIVED BY, -DATE PERM.yIT NO. <br /> yw_` �7 g <br /> a.EH 13-24{REV.t/H51 I W � }� �g <br /> EH 14-26 ca­ L <br />