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l APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZET ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. a <br /> Job Address I'IQ City 51 <br /> G n Lot Size /1d K/3�r PM <br /> Owner's Name ;Duy"e Na /Z 0, Address -,0— Phone <br /> Contractor.�1�-_(1V L' wc/- Address 7,_IV.', �[ �C/�� License No. 7-ZJ'a�� Phone����9� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <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 WELLry T PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS _ <br /> ❑ Industrial ❑ Open Bottom E'Manteca Dia. of Well Excavation ' Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy- Type of Casing t Specifications <br />" f`1 Public $ ❑ Other n Delta" Depth of Grout Seal "Type of Grout _ <br /> I 1 Irrigation Approx. Depth I.] Eastern Surface SeaP Installed by �- <br />' Repair Work Done ❑ Type of Pump H.P. - StateWorkDone <br /> 'Well Destruction ❑ Well Diameter Sealing Material ?top 501 <br /> Depth I Filler Material (Below 501 <br /> ~TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDIT_ION DESTRUCTION € I (No septic system permitted if public sewer is <br /> - 4 _ available within 200 feet? <br /> -Installation will serve: Residence Y ' Commercial . Other N <br /> r <br /> Number of living units: —JL Number of bedrooms, <br /> Character of soil to a depth of 3 feet: G�u U Water table- <br /> depth <br /> r <br /> $EPACTANK . ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distancetonearest: Well Foundation Property:Uney <br /> LEACHING LINE Ne�No. &-Length of lines 9 010 Total length/size X T UU <br /> FILTER BED ❑ Distance'to nearest: Wel{ Foundation Property Line <br /> SEEPAGE PITS ; Depth € Z� Size -36 Number 1 <br /> SUMPS ❑ DistaKee�to nearest: F ndation 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. 4: <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."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 /> r <br /> The applicant must call for all required inspections. C plete drawing on reverse side. x <br /> Signed X..,.aZ Title: _ C_ Date: <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 'L��Yt�� « �,.\I.iwwrti Date � Area <br /> Pit or Grout Inspection by Date Final Inspection by .� Date <br /> r f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621-- --H Manteca "823-7104_ :fl ❑ Tracy-835=6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ? I <br /> ! INFO FEE AMOUNT DUE I AMOUNT REMITTED �J C-ySH-- ­RECERIED BY DATE PERMIT NO. <br /> +.EH13-241AEV.t/Ns) oe (/V 7Dr,90 go-3'`1 <br /> EH 14-M <br />