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M <br /> f k APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { 1601 E. HAZEL•iON".A`VE., STOCKTON', CA <br /> Telephone (209) 466-6781 <br /> e <br /> e PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> l h'�7rt-� <br /> (Complete in Triplicate) <br /> Application is heteby 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 welt/pump and the Rules and Regulations of the San Joaquin <br /> t Local Health District. <br /> I Job Address Qw F Q <br /> � City Lot Size PM - <br /> Owner's Name address <br /> I hone <br /> E Contractors Address <br /> License No- Phone <br /> TYPE OF WELL./PUMP: NEW WE ELL REPLACEMENT DESTRUCTION <br /> PUMP INS TION I� EPAfR ❑ ER ❑ <br /> DISTANCE TO NEAR ES_T:..SEPTI C YTA K'�_ /.k SEWER LINES DISPOSAL FLD.��Q+PROP. LINE <br /> . -• . .� _-FOUNDATION:. AGRICULTURE-WELL, OTHER-WELLSO 1 PITS/SUMPS <br /> i, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> I Dia. of Well Casing <br /> Q Domestic/Private l�ttravel Pack ❑_�Tracy Type of Casing Specifications <br /> �ublic ❑ Other I�Delta Depth of Grout Seal tz <br /> Type of Grout <br /> I I Irrigation _Approx depth I 1 E stern Surface.Seal installed by •�,rr — <br /> Repair Work Done ./ Type of Pump H.p, State Work Done j <br /> - Well Destruction Well Diameter �6ealing Material (top 56') _k),n �+ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'i Rl ['AIR/ADDITION I i DE57RUC ION I 1 {No se tic system permitted:wputilic sewer is CJ <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) 11.X <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet:I Water table depth <br /> SEPTIC TANKs <br /> ❑ Type/Mfg,, Capacity. No. Compartments -� <br /> PKG. TREATMENT PLT. ❑ r <br /> Method of Disposal { <br /> Distance to nearest: Well Foundation Property Line t <br /> LEACHING LINE ❑ No. & Length of linest <br /> Total length/size. <br /> .FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size _ Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line ' <br /> DISPOSAL PONDS Eli <br /> - t t <br /> I hereby certify that f 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 Joaquin1ocal Health District. <br /> Home owner or licensed agent's signature certifies ttie following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> em in such manner as to become subject�to workman's compensation laws of California Contractor's hiring or sub-contracting signature r <br /> ce ifies the followin I certify thatn the performs of the work for which this permit is'issued, I shall employ persons subject-to workman's compensa- l <br /> ti n laws of Califomi ,s ! <br /> Th applica u cal or all r quire" i, plat -drawing on a sid <br /> Signed <br /> - Title:' fJQ f <br /> Date: �a� ...— <br /> i �y FOR•_DEPARTMENT USE ONLY <br /> Application Accepted by A <br /> Date r f <br /> F 3�..� ,or Finalrea <br /> Pit or Grout Inspection b ..� s-� Date l� Inspection by f $� <br /> Dated_ <br /> VAdditional Comments: �,{�r Z <br /> �❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy., 835-6385�x 1 ' T° <br /> pplicant- Return all copies'toc Envir nmental Heal hPermit/Servicas'1601`E:'Hazeltbn Ave., P"O. Box-2ob9," i -,'C 95201' <br /> 3�b�� ( �Y` - ura:o -v rte:$ `_�t ��Q�d weQP <br /> IN <br /> FEE AMOUNT'DUE AMOUNT REMITTED CK RECEIVED BY <br /> CASH DATE PERMIT'NO. <br /> EH 13-24♦.EH 14-2g 1AEV.t/>!5) 1+ �� 4:2q_L4 .k <br /> c� 1 '1 <br />