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rt7 r APPLICATION FOR PERMIT <br /> -� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE:1,1 STOCKTON, CA <br /> Telephone (209)'1466-678-1 <br /> PERMIT EXPIRES 1 YEAR FROM,.DATE ISSUED t <br /> (Complete in T!Iplicate) , <br /> App(cation is hereby made to the Sad Joaquin Local Health District fog a permit to construct and/or install the work herein described. This application is <br /> ma in compliance with San Joaquin County Ordin2nce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Loc I Health District. rI ri <br /> qy z ;Adpress _ I tl �Gt_tsr f1i L YEA• City ! Lot Size PM <br /> O feIVami3 0!r11/ ZQ'V'e�� Address a L#7. r_ 7 ��_A. D ._fsL+ Phone T Q <br /> t" Contractor Gt/ fr =a y Address'- ✓ - /t License No. ��-�Z- Phone[ A1 <br /> TYPE OF WELL/PUMP'. . NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ / <br /> d; <br /> 13IS7AN�E TO NEAREST: SEPTIC TANK _ SEWER LINES �M. _ DISPOSAL FLD.,f n2 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI !f <br /> © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing!/� <br /> �DomesticlPrivate XiGravel ck ETracy Type of Casing G Specifications 11pQ �f <br /> r-I Public he('� Ll Delta Depth of!4Grout Seal Type of Grout . <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by_Ocua s°6= _ <br /> Repair Work.Done ❑ Type of Pump H.P. �M State Work Done <br /> Well Destruction O Well Diameter Sealing Material flop 50'1 1 <br /> Depth Filler Material f8el4v 501 — ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> ` available within 200 feet.) � ) <br /> Installation will serve: Residence_ Commercial_ Other ! Q <br /> Number of living units: Number of bedrooms <br /> Character of soil to-a depth of 3 feet: M Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ If Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> �6 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line — l <br /> SEEPAGE PITS i I Depth Size i� Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ IN. <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 following: "I certify,that in the performance of the work for which this permit is issued, I shall not f" ` <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 applicaZ=�Vqu' d ' spactians. Complete drawing on re rsa side. <br /> Signed X Title: Dasa: <br /> -�7-�1' <br /> IM <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by I1 Date Area <br /> Pit oGrou Inspection b Dat ei�/ Final Inspection b Dat <br /> t� <br /> Additional Comments: I� ] <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 /> I� 1 <br /> IFEEO AMOUNT DUE AMOUNT REMITTED CK 4 CASH fRECEIVED BY DATE PERMIT-NO. I <br /> + EN 13.24(FEV.I/H 51 ? } CIA?k <br /> 1 0 1 <br /> EH 14-2e <br />