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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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. <br /> 1 j� �y I <br /> Job Address d Li o so 1„ k. City k� <br /> Lot Size � PM <br /> Owner's Name. Address Phone <br /> �t f fi�J.cam ,;�.;1•� .+�,,p n <br /> Contracts +� & Address 1 ID' �7 ��0 r License No. -L-Z(- Phone 3�og"S�OS <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 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> }O'Industrial_� _ LJ_Open_Bottom ,i] Manteca' y �-bia.`of W6VExcavation Dia. of Well Casing <br /> 41 <br /> ❑ 6 mestic/Private ❑--Gravel,Pack`__._ ❑Tracy--. Type-of-Casing Specifications <br /> I'1 Public ❑ Other ❑ Delta Depth of Grout Seal S. Type of Grout _ <br /> I Irrigation —.Approx. Depth l ],{Eastern Surface Seal Installed by _ n I <br /> Repair Work Done 71Type of-P`p ..—� - H:P _ "� _'_. `.tel�,f State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> yy , <br /> Depth 'ller.Material_(Below�50:)., --'O" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la EPAI ADDITION DESTRUCTION I l (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence____- Commercial—/Other <br /> Number of living units: Number,off b� roo_m •_,'Sy.., f j• H a ,au �.� l r` <br /> Character of soil to a depth-of 3-feet: Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg, f 1 + Capacity `� =. -N9.,Compartments <br /> PKG. TREATMENT PLT. ❑ �' �.•, tiR Method of Disposal , <br /> Distance to nearest: Well Foundation_ PropertyLine. <br /> LEACHING LINE f � No. & Length of lines � Q� •' Yr �Total_IengtFi%size=� X <br /> FILTER BED _-0 Distance.to nearest: Well Q-�._ . Foundation:� ' <br /> Property:Line . <br /> SEEPAGE PITS I I Depth '7 Size."` � _Vq X ��t-- �'-N�uumm�b;�er <br /> SUMPS ,Distance to nea`resr'.�"'�"Utilill--00 ''`Foundation� PFaperty Line� E <br /> DISPOSAL PONDS ❑'F 1 <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: "]•certify that in the performance of tFie'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 Californias Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I.shal a nploy_persons subject to workman's compensa- 4 <br /> tion laws of California." _ <br /> f <br /> The applicant 6IKt call for eq ed inspections. Complete drawing on reverses <br /> Signed X�� Title: Date: <br /> 0� Q <br /> a FOR D IRARTMENT USE ONLY <br /> �Gn <br /> epted by Date Z Area <br /> . tion by ate ` inal Inspection by DateIF <br /> - Z <br /> r <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 INFO JA/MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEGP�ERMiT�'7NO. �q <br /> ..EH 13-21 tREV.tixsl .! / O J pc <br /> EH 14-26 <br />