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1 <br /> I' <br /> • ._ 4 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'/ Zt: <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 3xo� SV�� /C CI�, /1Ao"t 3 PM <br /> r <br /> 5 T/aC�Tl> of Size <br /> Owner's Name �/ b � "T .AcIdress �'��' R� /2�I1� W#V Y-- Phone —3zles)l <br /> Contractor k4�A F ddress 2Z.2ek(dZ/.4e-4Y e6QLicense No. 8L Phone <br /> 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X7 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , <br /> -FOUNDATION'�"= 'AGRICULTURE-WELL, ->"- -OTHER WELL' `- PIT57SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 j <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ^ <br /> available within 200 feet.) y' <br /> Installation will serve: 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal j <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 1 Foundation Property Line 1 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> li;�u SUMPS, r r_ ,_,❑s Distance to nearest: _ Well. Foundation-. _ -- _P_roperty Line ., <br /> ..� �DISPOSAL PO r -. _. �_ _ <br /> pS.,v . <br /> I hereby certify ! .jd haves prepar �us'application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regul ; s`qf the San', agvin Local Health District. � •f <br /> Home owner or sed a6Avs sl�nit"tire certifies the following: "I certify that in tFie•pe_rformance of the work for which this permit is issuedt,I shall not <br /> employ any pe n such[nanneNs i become subject to workman's compensation laws of California." Contractor's hiring or sub-contractinWlsignature_ <br /> certifies the followipg:',I certify that w>.a performance of the work for'which this permit is issued;'I shall employ parsons subject to workman's compensa- <br /> tion laws of Cawdrwa.' <br /> The applicant -Trust tail f req J inspections. Complete,drawin')onre <br /> re <br /> t <br /> Signed X Title: " Date:rn <br /> "s s 1 F,OR D PARTMENT-USE ONLY p <br /> f-i� Q Q <br /> Application AcCrepfe E i Date ! Area , <br /> 4 <br /> Pit or Grout Inspection by II Date Final Inspection by --Date <br /> :'Additionil 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 /> INFO LCK <br /> FEELC- <br /> DUE AMOUNT REMITTED /fCASH �RfCEIV.ED.BY DATE PERMIT NO. <br /> + Ek 13-24 1 REV.1/s 51 �y�' N. t� <br /> EH 1428 { 7 �'�/i O �S N <br />