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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 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made;fo 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 IJS *51 I"T�if}�ir City Lot Size �✓ k �� PM <br /> E <br /> Owner's Name tI4 Address $2"k 45' J4ddQbc #44e2> Phone 5A­)3- 6 O� <br /> Contractor's <br /> Name License License No. l+('� -__ Phonea7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 11 <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 <br /> � ❑ Industrial 11 Open Bottom 13 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' •k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other D 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 p� <br /> Well.Destruction ❑ Well Diameter Sealing Material (top 50') W <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION.❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence >< Commercial_ Other <br /> {-� Number of living units: / Number of bedrooms / .--, <br /> I j} Character of soil to a depth of 3 feet: Water table depth <br /> ` SEPTIC TANK Type/Mfg �� ST— Capacity"ZZAM? No. Compartments �- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines :5 '— `? ! Total length/size 72116 <br /> FILTER BED ❑ Distance to nearest: Well /6�9 Foundation /3'a Property Line <br /> SEEPAGE PITS El Depth Size Number <br /> SUMPS 1-1Distance to nearest: Well Foundation Property Line <br /> }{ DISPOSAL PONDS ❑ <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: "1 certify that in the performance of the work forwhichthis permit is issued, I shall not <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 Calif rnia." <br /> The appiica t st all for al wired " s ctio om drawin on r erre side. <br /> i <br /> # Signed X Title: Date: cam"` <br /> g FOR DEPARTMENT USE ONLY + / <br /> ' Application Accepted by f F F f Date ':Z-�f)�� 7 Area <br /> Pit or Grout Inspection by WIN Date Final Inspection by n %e.* — Date, <br /> Ad_ditlonai.:Com'nts <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 <br /> lFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> +EH 13-24 MEV.10/83) 1 6 Q c ~ a�'—f`1"�r► �-1 7+ `E"'!<.� <br />