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l� d� APPLICATION FOR PERMIT <br /> all SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1 r'l 1601 E. HA'Z'ELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> LO 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 /> r local Health District. <br /> Job AddressCity Lot Size PM <br /> i <br /> Owner's Name A4A�tlress _ Phone <br /> ContractorAW <br /> /VS Address License No. 99 Phone Z <br /> r TYPE OF WELL/PUMP: ' ''NEIN WELL' WELL REPLACEMENT DESTRUCTIO L,G `7 <br /> PUMP•INSTALtATiON- SYSTEM-REPAIR-B--OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.'YJ PROP. LINE `;r <br /> FOUNDATION P AGRICULTURE WELL tOTHER WELL PITS/SUMPS & <br /> INTENDED USE TYPE OF WELL PROS LEMkAR A CONSTRUC-TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia." of Wei( Excavation 119, Dia. of Well Casing <br /> Domestic/Private ravel Pack ❑ Tracy Type of Casing Specifications <br /> I`l Public F Other ❑ Delta Depth of Grout Seal Type of Grout <br /> -I-I irrigation ,,.—Approx. Depth—i-i-Eastern fSurfaca-Seal-Installed by ti <br /> Repair Work Done Q Type of Pum ! ` H.P. 1 }_ Stag+g Work Done <br /> I Well Destruction Well Diameter ` ��~�Sealing Material ltop-50'I �-cTv »° <br /> Dep[h��� ` Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INST-ALLATION_(_I_�REP'AIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is p _ <br /> available within 200 feet.); llpl� <br /> I Installation will serve: Residence_ Commercial .Other Mfr t i� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: � t 1r. Water table depth 6 <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1'r`. No. Compartments X, <br /> II PKG. TREATMENT PLT. ❑ ^F :ffY Method of Disposal <br /> Distance to nearest: Well Foundations� y Property Line <br /> LEACHING LINE ❑ No. & Length of lines —' totaI_WhlJth/,size-- 1"> <br /> FILTER BED ❑ . Distance to nearest: Well )Foundation Property Line ` l <br /> SEEPAGE PITS I 1 Depth Size _ 1 Number <br /> SUMPS L� Distance to nearest: Well ( I Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify tha%I have prepared this application and that the work will be•d'one in accordance with'tan Joaquin county ordinances, state laws, and <br /> i rules and regulatinns�of 1h'e.San,Joaquin lLocal Health�Distr`ct. ---- t �' fid j 1 <br /> Home owner or licensed agent's signtittu a certifies the fo)lowing: "I ce6fy`atin the performance of the work tor,which this permit is issued, I shall not <br /> employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or,sub-contracting signature <br /> E certifies the following: "I certify that in the performance of the work for which this permit is issued;IlshalLempldy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantall re pections. Complete drawing on reverse side. 7711 -t+ <br /> Signed X Title: ✓ ¢Date: <br /> Al <br /> t FOR DEPARTMENT USE NL�'� / <br /> Application Accepted byi Date Jea <br /> r� 1 f � <br /> Pit or rout Inspection by�� U Date L� 1 / yFinaa nnls'pecction by I Date <br /> Additional Comments: Uh4 �rrAW, <br /> ❑ Stk 466-6781 0 Lodi 369-3621 1 ❑ Manteca 823- 104 d Tracy 835-6385 <br /> I <br /> Applicant- Return all copies to: Environmer'al Health,PerMit/. rvices 1601-E-. Hazelton Ave-'P-0-86x 200tk., CA,95201 <br /> FEE AMOUNT DUE ' AMOUNT REMITTED CK RECEIVED BY bATeW PERMIT'NO. <br /> INFO CASH / <br /> . �� <br /> + EH 13-24IRE <br /> V. kf <br /> EH 14-2e 4/B5f �^" • / <br /> -7---,,, 5Z<1-1-7 5?1 <br />