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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f (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. ,` <br /> Job Address roo S��L�O Ave— City 1')A*t` e(A Lot Size PM <br /> i\ <br /> Owner's Name tC��AR� m C,7 ss 4 �A3 S !s <br /> Phone <br /> Contractor ! 1 RGtI°e Address ISP "�U?�'� e License No. 2 739/8 Phone 9:13 -GS <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <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 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack D Trac Type ype of Casing Specifications <br /> (`l Public (_1 Other ❑ Delta Depth of Grout Seal Type of Grout----- <br /> I <br /> rout—W _I f Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth — =i — -Filler-Material {Belo -501) y -* <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION Or DESTRUCTION l I (No septic system permitted if public sewer is <br /> # t available within 200 feet.) <br /> ` <br /> Installation will serve: Residence�5 Commercial— Other G <br /> v <br /> I Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC.TANK VN <br /> �7�•pe/Mfg Gapa }y No. Compartments d <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> f Distance to nearest: Well Foundation { Property Line <br /> F <br /> f LEACHING LINE <No. & Length of lines Total Length/size <br /> FILTER BER = ❑ Distance to nearest: Well Foundation Property Line h <br /> SEEPAGE PITS I I Depth �� Size/_I �V X 12, N_ y umber <br /> SUMPS i &+•Distance to neare <br /> Foun <br /> st: 4" Well C�11' dation' Property Line <br /> O } f <br /> DISPOSAL PONDS ❑ <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 taws, and <br /> ...I.rules and regulations-of-the-San Joaquin-L-ocaf-Health-•Di§trict. + j <br /> Home owner or licensed agent's signature-deriifies the following; "I certify that in the performance of the work.far which this permit is issued, I shall not <br /> employ any person in such manner.96 to become subject to workman's compensation-laws of California." Contractor s hiring or sub-contracting signature <br /> certifies the following: "I certify'fhat in the performs a of the work for which this permit is.issued, I shall employ,persons subject to workman's compensa- <br /> tion laws of �alifomia." .� <br /> r The applicant m jg�for all require inspections! o mplete drawing on reverse.,side. <br /> Signed XData <br /> 3- 1-7o. 1,QQ <br /> Tiile: - : l <br /> F FOR DEPARTMENT USE ONLY , 1 �� <br /> Application Ac pted by :Date", rea <br /> f t y <br /> .Pit or Grout'/Inspection by f Date *+ Final Enspecti�.by� Date <br /> >Additional Comments: /? r <br /> j❑ Stk 466-6781 LJ Lodi 369-3621 ❑ M tea 823-7104 ❑ Tr y 835-6385 <br /> `Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009„Stk., A 95201 <br /> FEE AMOUNT DILE AMOUNT REMITTED <br /> INFO H RECEIVED BY DATE PgRMIT'NO. <br /> r.EH 13-24[REV.1/x 51 ,..e `/_k/ <br /> EH 14-26 / �p�lt s <br />