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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. � A �, / <br /> Job Address , /0%(/.7Qi 1S•1 l"_it').r9VIL, /T v+ Cit Lot Size(92,^ A?X A/f� PM <br /> Owners-Na Address._ Q �/ S �f L 7�.C? (f�Phorse T`= <br /> ---_ <br /> Contractor's Na a (S License No. Phon� <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT .0 DESTRUCTION ❑ <br /> j PUMP INSTALLATION ❑ SYSTEM REPAIRa7 OTHER ❑Y <br /> DISTANCE TO NEARES : SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS =� <br /> IN1'ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrie] ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'J <br /> .1 Nt ytPomestic/Privi to ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> a ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ` <br /> r - <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work pan ❑ T}r�e af'Pdmp"" H.P. State Work Done <br /> Well Destruction l(❑ Well Dia"r Sealing Material {top 501 <br /> Ow_4 lf� <br /> Depth Filter Material (Below 501 V S <br /> TYPE OF SEPTIC:WORk`--NEV4.1NSST*LM--TION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.] (� <br /> Installation will serve:I Residence_ Commercial— Other <br /> Number of living units. Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK i ! 1)( Type/Mfg '.i` Capacity A6,00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ 7 <br /> Method of Disposal <br /> n <br /> Distance to nearest: Wel 417 4- Foundation A0 Property Line 4000.1 <br /> t <br /> t � <br /> LEACHING LINE �4(_No- & Length of lines"" To;al length/size <br /> a <br /> FILTER BED ��fl' Distance to nearest: WeIL,�C>42-7�t Fo'u'ndation Property Line <br /> SEEPAGE PITS C1Depth Z 9 Size J Number <br /> SUMPS AC Distance to nearest: Weu��I± Foundation,__47V,/'A"" Property Line A000 f <br /> DiSPOS" ONDS ❑ i �' C� i <br /> hereby certify that I have prepared this application and that the work will be done•in.accord_dnce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensee-agent's rf <br /> ent's signature.certifies the following:_J-certify that in the ormance of the work for which this permit is issued, 1 shall not <br /> B`mploy anytperson in such manner as to become subject to workmns <br /> an's compeation IAws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that tri the performance of the work for which this permh isitsued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The applicant mu II for allr quiireed inspections. Complete drawing on reverse side.. <br /> Signed 'v Title: —� Date: <br /> �FOR DEPARTMENT.USE ONLY <br /> Application Accepted by > Date i Area <br /> Pit or Grout Inspection by IDate ` Final Inspection by Date U • <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 .., ❑ Manteca .823-7104 ❑-7racy 835-6385 <br /> Applicant- Return all copies to: Erivironfnentai Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24 IREV.10183) � _ i1..1 r�.l� 1z,131 z, .� <br /> EH 1128 �/ �1 "F-a <br />