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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601-E. HAZE i 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 /> ., Job Address_ ° �}P i� /DQE. lnin 4l City Lot Size Z© pm <br /> Owner's Nameve vrrna�/t /7 te" Address Phone �'3� <br /> Contract Gb �.'Address P0. 7J&X ~lf 7.- [� License No.,K� . <br /> �_ Phone <br /> TYPE OF WELT./PUMP: NEW WELL ❑��` ._ WELL REPLACEMENT.O ; DESTRUCTION ❑ <br /> PUMP INSTALLATION❑---- - SYSTEM REPAIR ❑v` OTHER ❑ Y <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 c <br /> r <br /> ❑ Industrial ❑ Open"Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private­0, vveel,Pacck ❑-Tracy- Type of Casing Specifications <br /> ❑ Public ❑_ -Oiher ❑ 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 ` YSealing Miteriat"{top 50'I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 2`_REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> -'Installation will serve:..Residence f---Commercial_ Other <br /> Number of living units:' Number of b drooms <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK UR—Type/Mfg CapaciNo. Compartments <br /> PKG. TREATMENT PLT. ❑ r , Method of Disposal <br /> Distance to nearest: Well _ Foundation /D Property Line <br /> C.l r <br /> LEACHING LINE flYNo. & Length of lines � YD Total length/size X <br /> � <br /> FILTER BED C1Distance to nearest: Well • ,�6 Foundation J61 Property Line $ <br /> SEEPAGE PITS El DepthSize Nb <br /> - umer �' r <br /> SUMPS ❑ Distance to nearest: Well /06 Foundation Z 0 ` Property Lie <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari 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: "I certify that in the performance of the 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 California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust all for re fired inspections. Complete drawing on reverse e. <br /> Signed Title: Date-.1/ <br /> FOR DEPARTMENT USE ONLY 1 <br /> t " -Application Accepted by - - ' -Date J .Area <br /> Pit or Grout Inspection by Date luzZ Final Inspection by 0,f Date+ 2 <br /> F <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 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT'NO. <br /> INFO // �r <br /> 4IREV.1/66) © � ` ,o -Igg 8 <br /> �, <br />