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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 /> r <br /> (Complete in Triplicate) / — <br /> 2-CeO� <br /> App ten 6y made to the San Joaquin Local ee11h 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 /> I Job Address .,y ilL/ �T City �/�6I! Lot Size pM F <br /> Owner's Name z Addressy ,P. LFA <br /> r'� /� Phone 8-3d <br /> Contractor Address 11 License No.1.agr2iz Phone 0;0�1t> <br /> lr <br /> TYPE OF WELL/PUMP: NEW WELL n WELL REPLACE NT ❑ DESTRUCTION 9, <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 t <br /> 0 Industrial Cl Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing / (' <br /> ❑ Domestic/Private ❑Gravel Peck 0 Tracy Type of Casing Specifications <br /> M Public n Other n Delta Depth of Grout Seal Type of Grout 6'1 <br /> I I Irrigation <br /> —.Approx. Depth I 1 Eastern Surface Seal Installed by as i <br /> Repair Work Done ❑ Type of Pump H.P.- <br /> State Work Done _ <br /> Well Destmction Qt Well DiameterSealing Material (top 50'1 <br /> Depth ( Filler Material fBebw,501 <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION 1 1 INo septic system <br /> Permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 1 <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet:I -Water table depth <br /> SEPTIC TANK' ❑ Type/Mfg l Capacity No. Compartments r <br /> PKG. TREATMENT PLT.❑ Method of Disposal ' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 6 Length of lines Total length/size <br /> FILTER BED 0, Distance tlr nearest: - Well Foundation Property Line <br /> I _ <br /> SEEPAGE PITS - I I Depth { Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line )' <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 1 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed en 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 s h net as become subject to workman's compensation laws of California."Contractor's hiring <br /> certifies the following: 'I ce that i ng or sutrcontracting signature <br /> Flak <br /> per ante of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion Taws of C." rni / t <br /> .The applicant mus I o el re ui irons. Complete drawing on reverse s' e <br /> i / <br /> Signed X Tltk: Date: <br /> ,�( FOR DEPARTMENT USENLY ' <br /> Application Accepted by uc 1/1 ill. !i/ Date (L Q LJI <br /> ea <br /> Plt or Grout Ins <br /> pection by Date Final Inspection by <br /> Additional Comments: r <br /> ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7106 0 Tracy M"M <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95101 <br /> I <br /> i <br /> FEE AMOUNT DUE MOUNT REMITTED <br /> INFO I CASH RECEIVED BV DATE PERMIT'NO. <br /> • FH 1324111V,r/X51 <br /> FH11.]a 1—ao-`r�8 ���� <br />