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f <br /> -APPLICATION FOR PERMIT <br /> •� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> 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. ��}} .� ,n <br /> Job Address � <br /> Ci Lot Size& �[� PM <br /> Owner'sName �i,G Address I <br /> t <br /> Phone <br /> Cpntrae2e;C �' CMZ G"Addt4 - ress r / O 6z , License No,` �Z 7 Phone_ �1`-S/C/ <br /> iTYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> f 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public 1.7 Other t-! Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Easten. pp . pSurface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ <br /> Well Destruction Q Well Diameter Sealing Material (top 50') <br /> Depth <br /> Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residencet/ Commercial_ Cher <br /> Number of living units: _Z_.-_ Number of be rooms f / <br /> Character of soil to a dept of 3 feet: ,y.. (/1J'� Water table depth `� Q <br /> SEPTIC TANK Type/Mfg ?�:' 7LGC!r-� Ca acit r g; <br /> R Y No. Compartments ll" <br /> e PKG. TREATMENT PLT. f 7 / Method of Disrposal <br /> Distance to nearest: Well t�Cl— Foundation __._ Property Line e <br /> LEACHING LINE No. & Length of lines '_ Total length/size X.2 <br /> FILTER BED ❑ Distance to nearest: Weil � <br /> Foundation- 1/2 ___._ Property Line , <br /> SEEPAGE PITS Depth Size _ Number <br /> SUMPS L1 Distance to nearest: Well <br /> 714d f _,62QY <br /> _ 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 3 <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 <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 applicant mu c for all requi ins ctions. Complete drawing on reverse side. J <br /> / t <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> E Application Accepted by <br /> Date Area <br /> or Grout Inspection by ate Final Inspection by '✓ Date <br /> Additional Comments: <br /> 0 Stk 466-6781 O Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM)7 <br /> INFO y... CASH �] NO.. " <br /> I.i4-2/1REV,ofHs) ` /J A C <br /> 14-29 J � �/(�• VUC 1 /� <br />