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k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA?'._r4• <br /> I } Telephone {209) 466-6781 .:' � <br /> NED <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSOED <br /> {Complete in Triplicate} -U el <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',h'e�Rules and;Regulationslof the San Joaquin <br /> Local Health District. �l.,S.0 '6­ <br /> SO U-7-1-( <br /> Job Address -1FZ'PL DE U—A Lot Size PM <br /> 3� l A <br /> Owner's Name ice- L`�1 � Address VIDA DR,�l-bpit � phone <br /> Contractor �a qg N AddressDicense No. �(] j Phone <br />! TYPE OF WELL/PUMP: NEW WELL EJ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLVATION SYSTEM-REPAIR ❑ t OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLb. ` PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ? 1 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 <br /> ❑ Industrial -.42-Open,Bottom ❑.Manteca,_ al,Well Excavation <br /> I.-Dia.-of-Well-Casing._, f*r� <br /> ❑ Domestic/Private LJ Gravel Pack C Tracy ri rType ofi Casing Specifications <br /> M PublicGroui�See1 - ti`"i <br /> iType'iiYGioUt _ <br /> I I Irrigation —.-Approx.-Depth 1€ I Eastern Surface Seal Installed by ` <br /> Repair Work Done ❑ Type of Pum <br /> YP pTa! H.P. z� State Work'Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 541 ;, k <br /> Depth Filler Material (Below 54'1 <br /> �'- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i'l REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 204 feet.) + Q <br /> Installation will serve. Residence— Commercial___ Other { ' <br /> Number of living units: Number of bedrooms 1 k <br /> Character of soil to a depth of 3 feet: Water table depth i . <br /> SEPTIC TANK ❑ Type/Mfg Capacity No; Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size' ; s <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property;Line <br /> i <br /> SEEPAGE PITS I I Depth Size _ Y _ Number <br /> SUMPSr <br /> • ❑ Distance to nearest: Well Foundation Property�Lii�e i <br /> DISPOSAL PONDS ❑ - _...- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San ordinances,Joaquin county nances, state laws, andy:'y 4 <br /> rules and regulations of the San Joaquin Local Health District. ; , i <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 no' s <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: ' c fy that in the performance of the work for which this permit is issued, I shall empldy persons subject to workman's compensa- <br /> tion laws of Califor ' <br /> The applicant m r all quired inspections. Complete drawing on rev, a ide. <br /> Signed X / <br /> Title: ` Date: _Z ,2/ <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ,.r, A L- Q <br /> Data Area <br /> Pit or Grout Inspection by Date Final Inspection by Date -3r1,-fYk„ <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 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 95241 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT'No. <br /> +.EH 13-241REV.Pius) ...2.��� 1 r� <br /> EH 14-2a - 11 l�� <br />