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4 <br /> APPLICATION FOR PERMIT <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> f 1601 E. HAZELTON AVE., STOCKTON, CA N <br /> tt Telephone (209) 466-6781 <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED e <br /> I <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 /> meds 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. O fF{ <br /> Job Address n (� * tf'W y Q-u C'N Lot Size PM <br /> Address 6 I .Phone <br /> Contractor's Name F License No.?' Phone <br /> TYPE OF WELL/PUMP: - -- .NEW WELL.,]- WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATIONI` AGRICULTURE WELL OTHER WELL-PITS/SUMP$ <br /> INTENDED USE TYPE OF WELL,^'n PROBLEM AREA CONSTRUCTION SPECIFICATIONS .. s <br /> ,Z] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack4—• CJ Tracy Type of Casing _ ^' Specifications , <br /> ❑ Public y ❑Other ❑ Delta Depth of Grout Seal .. Type of Grout. I�Aft: <br /> ❑ Irrigation _Approve.. Depth ❑ Eastern Surface Seal Installed by W <br /> Repair Work Done ❑ Typeaf' Cimp�r""- ��H.P. State Work Dane ,r <br /> Well Destruction ❑ Well Dia mew rti �. Sealing Material (top ST) S <br /> �., Depth I FillerrMaterial (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTAL7:ATION' , REPAIR/ADDITION O DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) 15 <br /> Installation will serve: Residence.JL Commercial_ Othe'r Y <br /> 1 cc <br /> Number of living units:�_ Number of bedro �' � C <br /> Character of soil to a depth of 3 feet: I Sa ri Y>- I �rS✓Yl . Water table depth <br /> SEPTIC TANK Type/Mfg %P.,Y L Capacity !a-'D71 1 No,Compartments. <br /> PKG, TREATMENT PLT. ❑ ' �„ .w:, - Method of asp I <br /> Distance to nearest: Well=1-aQ- Foundation Property 14. O <br /> . I trF� �, LOY. <br /> LEACHING LINE_,.PL,.No. &.Length of lines- y T Sr length/sae <br /> FILTER BED ❑ Distance to`nearesr Well:J�_ Foundation ys Property Line M 4-- <br /> i <br /> SEEPAGE PITS ❑ Depth 1' ..,{� 3be 1 ) Number 1 <br /> SUMPS ( El Distance tc nearest: Well Foundation ,Property Lille .- - <br /> DISPOSAL PONDS ❑ A v <br /> I hereby certify that t 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 District. <br /> . Home owner a licensed agem's signature certifies the following: J.certify that in the perromlanoe of the work for which this permit is issued,I shall not <br /> employ any person in tach manner as to become subject to workman's compensation laws of California."Contractoes hiring or sub-contracting signature <br /> I certifm the1vAow ng:_ ca (ySheFinthe-performance of the'wbrk'for.whiih'this permit is issued, 1 shall employ persala suhjact to workmen's compons i- <br /> tion laws of California." ' t �(.. ._ <br /> ( The applicant must'call for all required'',{ssplectiom. Complete drawing on reverse side. <br /> .. <br /> +( Signed X��` '� Title: a�tr7d Date: +O V v <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 11, <br /> Pit or Grout Inspection by Date Final Inspection b Data <br /> Additional Comments: ; <br /> ❑ Stk 46DOM1 ❑ Lodi 36&9621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <br /> Applicant-.Rehm all copies to: Environimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IH2f <br /> ' NFO AMOUNT DUE AMOUNT REMITTED COAKSN RECEN£D BY �/DATE PPRMIT'NO. <br /> a Qi 13.24 IAW.10/WI �S, 00 /It0/�CS gS <br /> Ee 1428 <br />