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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON.AVE., STOCKTON, CA <br /> 'feleph6ne (209) 466-6781 ' <br /> '" -f'+�-r .. , , , , .,f .. w!4 ­: i !:,. - ",I'l C'... I tr; <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 dos-c-rib&J.:This application is <br /> ,L <br /> rnade.in=F�npliance with San Joaquin County Ordinance No.549 for sewage or No.,1862 for w-911/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District—AJ,.M.1.1 lo rrA�V�11 <br /> Job Address Yo ao City Lot size Z,::57 <br /> Owner's Na <br /> -r - . Phone <br /> 2_ <br /> Contractor's Name <br /> ��-ZicenVp,NGq; 4 <br /> Phone <br />--;—.TYPE-OF WELL../PUMP: NEW WELL @r�_ J WELL REPLACEMENT F! DESTRUCTION 13 - - <br /> PUMP INSTALLATION_ <br /> '1\1"tYSTEMIREPAIR-El <br /> OTHER [I <br /> DISTANCE TO NEAREST: SEPTIC,.TANK - SEWER LINESI�-L. \�`-eDISPOSAL FLD. <br /> PROP. LINE Rjt2;0 <br /> FOUNDATION5-10 AGR16ULTU"RE Wkil_L� <br /> ;77q`'OTHER WELL PITS/SUMPS <br /> ' ` ' <br /> . <br /> 11�TENDED USE TYPEbF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION9 . <br /> D Industrial 0 Open'Botto EJ Manteca I Dia. of!well Excavation m Die. of Well,Casing <br /> El Domestic/Private @,-G—ravdll Pack El Tracy :�Spec <br /> . . 4 ... 61 Type�of Casing' �­ ' I ificat'i ns�Nl <br /> 0 Pfiblic El Other Delta �11 -Grout Sea] Type of G t <br /> Depth hof <br /> prox. Depth EJ Eastern Surface"Seal Installed-by <br /> Repair Work Done El Type of Pump H.P., <br /> State Work Done <br /> Well Destruction 11 r Well Dil'eter Sealing Material (t.op 1.50') <br /> DepthA <br /> Fller Ma <br /> terial (Below 501 <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION Ll REPAIR/,ADbITIOW0 DESTRUCTION Ll (No septic system pOmitted Jf public sewer <br /> I ( , Commercial <br /> I I � . r is��, <br /> available within 200 feet.) <br /> Installation will serve: ,Residencl— C cial O!therl <br /> ornmer, L <br /> Number of living units; Number of bedrooms <br /> \A <br /> Character of soil C, <br /> a a depth of 3 feet: <br /> 41. S 'Watertable deth <br /> N I <br /> SEPTIC TANK 4 17 Type fg. Canacre i I p <br /> tY V...No. Compartments <br /> PKG." TREATMENT PLT. IJ1 1.� V <br /> Method"Of Disposal <br /> Distance to nearest:' Well Fo'unclation <br /> Property Line <br /> t LEACHING LINE D No. 9-Length of lines <br /> 4 .. i — Total length/siz <br /> FILTER BED 13 'Distance to nearest: Well 1,_� L <br /> I _\ZFoundatidn Property Line— <br /> SEEPAGE PITS f L1 Depth Size Numberl Yr <br /> ,SUMPS.-% El Distante'to nearest: well Foundation t- L_-I' —Property Line <br /> DISPOSAL' <br /> L PONDS 0 N <br /> I hereby certify,that l have pr6pared:this application and that the work w&be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin-Local Health District. <br /> t <br /> Home owner or licensed agent's sigk�tuie certifies the folio following: "Icertify he be <br /> that in ��—rriyanc'e a,the work for which this permit is issued, I shalt not <br /> employ any person in such manner a'� to become subject to workman's compensation laws of California.)Contractor's-,hiringor sub-contracting signature <br /> S <br /> certifies the following: "I certify that! the performance of the work for which this permit is issued, I*shall employ person._.-Nect to workman's compense- <br /> --:tlon laws of Californiai"�_­, <br /> The applicant must II for <br /> aqLrequired inspections. Complete wi <br /> g on reverse side. <br /> Signed4Title: <br /> Date Z <br /> A <br /> FOR DEPARTMENT USE ONLY <br /> 4, <br /> 'Application Accepted by Date Area' <br /> 4- <br /> Y Dat <br /> Pit or Grout In' Flnal spection b Date ��=Flhl Inspection by <br /> :Additional Comments: <br /> C1 Stk 466-6781- ❑ Lodi 3691136211 0 Manteca- 823-7104 - 0 Tracy &35-M <br /> Applicant- Return all copies to: Environmental Heakh Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> TI NFEEF <br /> EO <br /> " -_-'AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY <br /> DATE <br /> CASH PMMIVNO. <br />+EH 13-24(REV.101831 <br /> EH 14-28 V41 <br />