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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 /> Appbcahnn m hereby made to the San Joaquin Loch 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 Ordvimrce No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,, �/ <br /> Job Address _htCDt•.Sp z�_C� �' 1w "s�cfity J}[.;��.-]_ Lot Size KL<91 <br /> )PM <br /> Owner's Name _c..LL_V�L �.�SwA,�ass �y_JsLQ�LN 2c, Phone 61LD <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [1 Industrial ❑ OPen Bottom ❑ Manteca Die. of Well Excavation Oia.of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I I Public ❑Other Fl Delta Depth of Grout Seal Type of Grout <br /> I litigation __ Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Dana U Type of Pump _._ H P. State Work Done _ <br /> Wea Destruction 11 Well Diameter _ Sealing Material(top 501 <br /> Depth Filler Matcnal(Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted d public sewer ie <br /> �J/ available within 200 feet.I <br /> Installation will serve: Residence 1 Commercial_ Other <br /> Number of living units: _t— Number of bedrooms_— <br /> Character of sod to a depth of 3 feet: .T Water table depth <br /> SEPTIC TANK �, Type/Mfg 40Capacity it _ No. Compartments <br /> PKG. TREATMENT PLT. (1 Method of Dispojal (' <br /> Distance to nearest Well Foundation_L� _ Property Line S9 <br /> LEACHING LINE (Y No. 6 Length of Eines Total length/lona 9Lr <br /> FILTER BED L) Distance to retreat: WOR—L4,0a * Foundation ._ Property Line AO <br /> SEEPAGE PITS I 1 Depth __ Size Number <br /> SUMPS [I Distance to nearest Well Foundation __ Property Line <br /> DISPOSAL PONDS II <br /> I hereby comfy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state lin,and <br /> rules and regulamns of the San Joaquin Local Health Di3lrict. <br /> Home owner or licensed agent'&signature certifies the following: "I certify that in the performance of the work for which this permit is iswed. 1 shalt not <br /> employ any parson m such manner as to beeorrw subject to workman's compensation lawn of California."Contractor's hiring c•orb-contraehrg signature <br /> certifies The following:"I certify that in the pnrformence of the work for which this permit is issued,1"D employ persons subject'.o y kman's corr4w a <br /> tion Isws of California." <br /> The applicant at call for aR u e- '.�ins�pec�tiio1�ttns. Compilers drawing on re�verrse side. <br /> Signed . �/s.IV •C. Title: Dam: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �� _ Date2� Area ] <br /> Pit or Grout Inspection by Data _ Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 4666781 O Lodi 3693621 ❑ Manteca 823.7104 O Tracy 835 63W, <br /> Applicant- Return as copies to: Environmental Health Permit/Servicas 16D1 E. Hazelton Ave., P.O. Box 2009. Srk., CA 95201 <br /> FEE <br /> K 4AMOUNT DUE AMOUNT REMITTED WHRECEIVFD By DATE PERMIT 140. <br /> NFO '! p <br /> Fw i&X <br />