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APPLICATION FOR PERMIT -� <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1`601 E. HAZELTON AVE.., STOCKTON, CA <br /> t 1'� Telephone (209) 466-6781 _ Y <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 1, <br /> F <br /> (Complete,in Triplicate). e <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. <br /> _ •� ��7 :+, a��l �"�� S'.�118 <br /> Job Address C� - �OJ-U City Lot Size �@'1.1 X S PM <br /> _ f _. _. . <br /> Owner's Name j�Ate A Yt�2 to A S % Address A(���iC &-e-�� r`l-L"e-. Phone a <br /> Contractor -►.f/l ~ 1` Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP I STLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES ISPOSAL FLD. PROP. LINE <br /> FOUNDAAGRICULTURE WEL OTHER WELL PITS/SUMPS ' <br /> INTENDED USE TYPE-OF-WELL '-,PROBLEM AREA— STRUCTION-SPECIFlCATIONS <br /> ❑ Ind ustrial t El Open Bottom ❑ ntec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ T y Type of Casing Specifications <br /> ❑ Public ❑ Other Delta Depth,iof Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx..D th ❑ Eastern urface•Seal'Installed by (� <br /> Repair Work Done El Type of Pu H.P. ` r State Work Done <br /> Well Destruction ❑ Well Diameter -� Sealing Material50 1 <br /> wr..' `Depth` Filler Material (Below ) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> ? "v i <br /> available within 200 feet.) � <br /> '4r <br /> Installation will serve: Residence Commercial_ Other *""�- -- ✓ <br /> Number of liwng'umts: ;Numb of bedrooms t <br /> Character of soil to a depth of 3 feet:' A` # Y / ater t depth <br /> SEPTIC TANK ❑ Type/Mfg Capaci No: Compartments r <br /> PKG. TREATMENT PLT. ❑ r _ s ; t " i <br /> " �`' ` _ i �� Method of Disposal <br /> ' Distance to nearest: r We Foundation Property Line. <br /> g f Total length/size <br /> LEACHING LINE ❑ No: & Len Length. s - t -- <br /> r FILTER BED ❑ Distanc nearest: t.Well oundation " Property_Line <br /> i f-SEEPAGE PITS ❑ epth Size Number 1 f <br /> SUMPS' ,;1, Distance to nearest: Well Foundatio - °' Property Line, A <br /> I DISPOSALi 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 and4egulations•of-.the_San_Joaquin-Local-Health,District.- <br /> Home <br /> istrict: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."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 persons subject to workman's compensa- <br /> tion laws of California." <br /> 4 The applicant must call for all required inspections. Complete drawing on reverse side. <br /> ?A,!t <br /> Signed X Gti � .f; Title: f�fl.�li.Q/� Date: 3 <br /> ��_, <br />! FOR DEPARTMENT USE ONLY <br /> Application Accepted by St) Date �w'' / Area Com' <br /> Pit or Grout Inspection by Date Fi/naspection by Date <br /> Additional Comments: 6Y� �( v r ��� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑-Manteca 823-7104 ❑ Tra4 835-6385' <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE{ INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> kk <br /> l ' EH 14-28(REV.t/as) 3_5 �® ��: '97 <br />