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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT R <br /> 1601 E. HAZE LI ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1yAR FROM DATE ISSUED <br /> I! (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. <br /> t .lob Address &'ct, o? P.4C_4f*= 6M7e_ _. _ City Ltl dl!I'I Lot Size PM <br /> y Owner's Name �� 1���. V 1' Address 7601'gf 1`k+Jr±4 .LA UdCA) Phone <br /> Address — — License No. o� Phone L3 <br /> Cont �• _ � <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1K SYSTEM REPAIR C1 OTHER ❑ CSIN <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ PITSISUM_PS <br /> INTENDED USE TYPE OF WELL PROBLEM�AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ IndustrialO n Bottom ❑ Manteca r 14 <br /> Yr, Pe " 'r Dia. of Excavation Dia. of Well Casing <br /> 1:1Domestic/Private O-Gravet,Pack ❑ Tracy Typ;)of"&d$ing ,5 Specifications 1(,cOX 34J� <br /> F] Public C1 Other fl pelta Depth of Grout Seal , Type of Grout <br /> f1k irrioation 530 r.Approx. Depth I I Eastern St*cg f eel Installed by I �T _ <br /> � Y <br /> Repair Work Done L Type of Pump I C. H.F. t i State Work Dane 4flezrJ wed�s BvnD by <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 �1 <br /> Depth Filler Mateiial (Below 50'1 <br /> TYPE-OF-SEPTIC WOAK;—NEW_INST.ALLATION la REPAIRIADDITION 1.1 DESTRUCTION I I Mo septic system permitted if public sewer is <br /> jr available within 200 feet.) <br /> Installation will serve: Residence,— Commercial Other <br /> � Number of living units: � Number of bedrooms <br /> Character of soil to a depth of'3 i t: ~"^ ---^— — •—Water-table-depth <br /> SEPTICTANK ❑ ;;Type1MfCapacity +yam _ _No Comparirtlents <br /> PKG.TREATMENT PLT.❑ ; ti ill" ,, Method of Disposal <br /> k Distance to rest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ "No. & Length of h Total length/sizei <br /> FILTER BED Q ,•Distance to nearest: Well Foundation Property jUrte <br /> I SEEPAGE PITS i I ::Depth Size Number <br /> I SUMPS 0 "Distance to nearest; Well Foundation Pro (Lina <br /> perty <br /> f DISPOSAL PONDS ❑ i <br /> I hereby cenify that 1 have piepared this application and that the work will be done in accordance with San 46Muin county ordinances,state laws, and y <br /> rules and regulations of the San Joaquin Local Health 011oict. <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pemut is issued, !shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California-"Contractoes hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws f alifornla." <br /> The !cant m a call fo all r <br /> PPl a uir inspectiana. Gogrplete drawing on arse side <br /> Signed Title: Date: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ��� �r3 Area-'# <br /> Pit or Grout Inspection by Date Final Inspection by� Date@ � <br /> Ir Additional Comments: <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. Hezelton Ave., P.O. Box 2009, Stk., CA 95MI <br /> I <br /> FEF AMOUNT DUE AMOUNT RITTED CAH CK <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> r+... <br /> i +.EH 11 142Z/ `IX6 <br /> 1IREY.r�aal +..7 <br /> _ EEH -2e 77 ffj <br />