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APPLICATION FOR PERMIT <br /> 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. N / / <br /> Job,Address �� r V�11/® V Cny O Lot Size <br /> pM <br /> Owner's Name 1 C k OR K�^r Address Phone /,3 <br /> �0[ont�cN� TE Address U �0 License No. Y-4 97 9/C Phone 3l- 3-2✓0 y <br /> TYPE: OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.,SEPTIC TANK SEINER LINES, - .DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS is <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> pecificatians <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation ---Approx. De El Eastern Surface Seal Installed by (A~ry <br /> Repair Work Done ❑ Type of Pump H.P. 4 <br /> State Work Done A O A/ 1fir/ 6 <br /> Well Destruction Well Diameter Sealing Material {top 5011 0 C L 0 T 0 041— <br /> Depth <br /> LLDepth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION LlDESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence�� Commercial— Other available within 200 feet.) Qn , <br /> Number of living units: NumbeF of bedrooms Yea{ <br /> Character of soil to a-depth of 3-feet:'- i <br /> Water table depth <br /> PKG. TREATMENT PLT. ❑ <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartmentsw. y- t <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> `r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FiLTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation + <br /> APOSAL PONDS i El Property Line <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 Califomia."Contractor's hiring or'-sLU-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California." f shall employ persons subject to workman's compensa <br /> Ti1e applicaneiff9 ..� all req ui ctions.-Complete drawin Y arse si T <br /> Signed !� <br /> y �;Q"r-• Titl A a IT�9 dr' 776iQ Date: <br /> FOR DEPA TMENT USE ONLY <br /> Application Accepted by Date A <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMrrrEp <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> -41 14-26 <br /> Ei13-244REV.1/65! 3S ` <br /> Y <br />