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r <br /> APPLICATION FOR PERMIT l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> J <br /> Application is heteby 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. 1 well/pump antd�the Rules and Regulations of the San Joaquin <br /> Local Health District. ( � A``N <br /> ,01 . W(?z'r r�Uc u ! !2 a Lot Size <br /> Job Address � • <br /> � �� <br /> PftORe <br /> -oLYNA� Address <br /> Owner's Name , (1.�� / ���f`7 / <br /> Contract <br /> t Address�� �o��ln �License Nor, ,;2e 7 2& Phone. �7S to <br /> • <br /> TYPE OF WELL/PUMP NEW WELL 0 '1NELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -' <br /> SYSTEM REPAIR ❑ OTHER El <br /> ,SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ _ � Y _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE- -TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C1, Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation - t <br /> YP <br /> T e of Casing Specifications � <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy g Type of Grout - <br /> FI Public C1 Other Cl Delta Depth of Grout Seal YP <br /> I 1 Irrigation _ Approx. Depth t 1 Eastern Surface Seal installed by --- <br /> Repair Work Done Type bf Pump H.P. State Work Done_ <br /> Well Destruction o ❑ Well Diameter __ t Sealing Material (top 50'1 — <br /> Depth . er Material (below 501 r�' <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION t I RE i'n!R ADDITION DESTRUCTION 1 1 (No septic system permitted it public sewer is <br /> ,rte available within 200 feet.) <br /> I <br /> Installation will serve: Residence X Commercial Other <br /> -L <br /> Number of living units: — Number ofI�edr�ooms /1 <br /> Character of soil to a depth of 3 feet: ` dna � 1_L#�Vy� _Water table depth_ <br /> ri <br /> SEPTIC TANK ❑ Type/Mfgr � _ Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> d n r { � <br /> LEACHING LINE No. & Length of lines 130 r �'4Q dotal length/size 0 � <br /> FILTER BED ❑ Distance to neafest. WeN 156 Foundation �_�i Property Line <br /> r <br /> t._SEEPAGE PITS t I Depth _Size Number ' <br /> SUMPS ❑ Distance to nearest: Well _ Foundation Property Line <br /> DISPOSAL PONDS Q <br /> I hereby certify that.1 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 D13trict. <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 t call for as requ'ed inspections. Complete drawing on reverse s '� -^ <br /> Title: Date: l?'i <br /> Signed X__-- _ _ _ _— <br /> FV11DPARTMENT USE ONLY <br /> Application Accepted by Date Area. <br /> Pit or Grout Inspection by Dare. - Final inspection by Data_21 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT No. <br /> INFO � <br /> ..EN 3.24(REv.I H 5) <br /> £H 7425 <br /> i <br />