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F. � .. <br /> k 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 /> 1 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 /> I Local Health District. <br /> Job Address City Lot Size PM . <br /> Owner's Name GAdAkccllIAJi Address Phone <br /> Contractor�QL1t .vl '� _ Address (Qw License No.ahu <br /> Phone . <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ f <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRI OTHER ❑ <br /> _DISTANCE 70 NEAREST: SEPTIC TANK i� S_EWER LINES_ r DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL� PITS <br /> INTENDED USE TYPE OF WELLPROBLEM AREA—CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 r Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingi 3 Specifications <br /> r Public f1 Other (_1 Delta Depth of Grout Seal f Type of Grout--.__ <br /> ] Irrigation —Approx. Depth I I Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump H,p- State Work Done <br /> Well Destruction 1=1 Well Diameter Sealing Material {top 50'} <br /> Depth �� _ Filler Material (Below 501 I _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION'[ l (No septic system permitted if public sewer is <br /> available within-200 feet.) <br /> Installation will serve: Residence_ Commercial w Other <br /> Number of living units: Number of bedrooms In\ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK: , ❑ T e/Mf Water table depth v <br /> /� YP 9 Capacity No. Compartments j <br /> PKG. TREATMENT PLT'. L-] . <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED--� ❑Distance to nearest: Well --�--- — Foundation - — -�---Pro ert L' <br /> +�� ,� P Y_ ine , <br /> SEEPAGE PITS I I-�Depth� Size _ Number t <br /> SUMPS L7 distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS D <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 followin I certify that in the r <br /> g g 9� �� Y performance of the work for which.this permit is issued, I shall not <br /> employ any peso such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the folio in9 "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 Cal'or a." l <br /> t f 1 <br /> The applic t st call for all re u red inspeMons. Complete drawing on eve side. <br /> Signed X Title:— — Date: t <br /> .d � i <br /> RTMEN USE ONLY <br /> Application Accepted by Date fl �t� Area <br /> Pit or Grout Inspection by Date Final Inspection by I Date <br /> Additional Comments: �4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Manteca 823-7104 ❑ Tracy 835-6385 F <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE MOUNT DUE AMOUNTREMITTED CK RECEIVED BY <br /> INFO DATE PERMIT-NO.ER 3-24 CASH (�j/J / �{/� off }n� <br /> +.EH 14-29[REV.t i H 51 �Y-/l [ `� C L' �C� /� / U 94 C �!IQ i <br />