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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT[ <br /> 1601 E HA2ELTON 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 desoibed. 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. / /j <br /> Job Address -f1-71S�� Clew to:�T"'��,, O '/ City---j.- ,rte Lot Size ' PM" <br /> Owne:s Name --7 f_ -% {>-/ . AR tZkr'Xdd}'ess _ !� }' tC1L Ly a I �Il rapid" '�' <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 17 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE •- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ P%TS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i ❑ Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> ❑ Domesue/Private ❑ Gfavel Pack ❑ Tracy Type of Casing Specications k <br /> I1 Public Ll Other CI Delta Depth of Grout Seal - Type of Grout ._ <br /> I I [organon Approx. Depth I 1 Eastern Sudaeo Sual Installed by <br /> Repair Work Done Cl Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material pop 50') ..r <br /> Depth Filler Material [Below 509 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONlI REPAIRIADDITiON i I DESTRUCTION I 1 INo septic systern twrmined if public sewer is <br /> available widen 200 feet.I <br /> Installation will serve: Residence V�Commercial_ Other _ <br /> Number of living units: _�"Number of bedrooms _ <br /> Character of seg to a depth�o.f 3 feet: Water table depth <br /> ♦ <br /> SEPTIC TANK; Cr type/Mfg I < Capacity— 11tO&e,n,I No. Compartments <br /> PKG. TREATMENT PLT. ❑ v Method of Disposal <br /> Distance to nearest: WegVoundation ? Pr <br /> .� A Foundation-wrQ gpeftV Lina <br /> LEACHING LINE 11-i—tdo. 8 Length of fines +/`.J Total lengWaize <br /> i <br /> FILTER BED f ❑ .Distance to merest: Well Foundation Property Lire <br /> SEEPAGE PITS fi.f'Daph 2, Sirs_?kP Number __ <br /> SUMPS LI Distance to honest: well Foundation Property Line <br /> DISPOSAL PONDS 17 <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 regulytions of the San Joaquin Local Health Di3ulct. _ .. <br /> Home owner or licensed agent's signature canities the following: "I certify that in the performance of"work for which this permit b issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Calitorhis."Contractor's hiring or sub-eentfacting signature <br /> certifies the f,wing: "I cartily that in the performance of the work for which this permit is issued,1 shell employ Persons wbiact to Workman's conponsa- <br /> tion laws of dorms." I I <br /> The ePPliea�en1-e must call for an required inspections. Complete dr <br /> W�/Fwtoo W reverse side. <br /> Signed !t � F !'1> itla: �.ti� Date <br /> FOR DEPARTMENT USE-ONLY ! <br /> i <br /> Application Accepted by , Data <br /> nby <br /> VqGrout InspectioFinal Inspection by <br /> Additional Comments: <br /> ❑ Six 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return a8 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - . e\ J <br /> .tiEeN 1R}a]et tIreEY. ncal NFO AMOUNT DUE AMnVo"o <br /> I <br /> Q f C\A�SH/�l� I gECE1VED eY /yVam. ��PATEV[r ytl�P�{tE}�RM.(l tnVJr NO, <br /> 1 <br />