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` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL*HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 descr,:rfbed. This application is <br /> er 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 7f <br /> _•:G <br /> ROL3/NDI4LE AVE _ city -S7"k/fir* Loi Size�/ ;}CQ,,� ply <br /> Owner's Name f Address Iv Phone <br /> Contractoaj�1R42t5R f� SO14' Address 14V2 License No.A5VU 3 Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE v <br /> FOUNDATION _ AGF',ICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL�PR13BiEM AREA CON TS RUCTION SPECIFICATIONS <br /> ❑ Industr; % ` ❑,Open Bottom ,❑-Manteca _ Dia. of Well Excavation Dia. of Well Casing 3 <br /> ❑ Domestic/Private ❑ Gravel Pack �� ❑ Tracy1 ' Type.of Casing Specifications <br /> 1-1Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern 5u_rface,SealFInstalled by 1 <br /> Repair Work Done ❑ Type of Pump H.P. F U # State Work pone_ <br /> Well Destruction El Well Diam a Sealing Material I {top 50')., t s <br /> Depth « - -r''Z:Filler Material-{Below 501}., �. 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION M DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> -- ^—i )-—availzible within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: 4- Number of bedrooms . <br /> Character of soil to a depth of 3 feet:� l Water table depth <br /> SEPTiC.TANK ❑ Type/Mfg! Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ r <br /> t l Method of Disposal <br /> Distance to nearest: Well yFdun-dati Property Lane <br /> LEACHING LINE 10 No. & Length of lines Total length/size 4 <br /> FILTER BED �=1—Distance-to•nearest:—Well—Foundation­��'^�-�'PrdWrrty Line #' <br /> r <br /> SEEPAGE PITS 91 Depth ;aS7 Size <br /> SUMPS,, ❑ Distance to.nearest: Well Foundation IV Property Line <br /> DISPOSAL PONDS ❑ _ <br /> �a I <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 I <br /> rules and regulations of the San Joaquin,Local Health District. <br /> Home owner Or licensed agents 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 /> r certifies the following: "1 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." li <br /> The appli t must call for all required inspections. Com late drawing on reverse side. <br /> Signed X Title: 0 Date: Ig <br /> i <br /> t FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> ��--- -6 Area <br /> Pit or Grout Inspection by Date Final Inspection by_, � �-�,. Date T� <br /> A ditional Comments: <br /> IX 466-6781 ❑ Lodi 359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE # <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> �4 <br /> + EH1428 <br /> 3.24 IREV.t i is 57 <br /> y EH 1 — a <br />