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APPLICATION FOR PERMIT sR #� <br /> SAN JOAQUIN LOCAL HEALTH DISTRIC y� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA AID # —..� <br /> Telephone 1209) 466-6781 �AC # <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISS F�` #µ �� <br /> (Complete in Triplicate) I i\ fir =_i..L�r,1r3 <br /> Application is hareby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein descn cation is <br /> made m compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reguiatiors of the San Joaquin <br /> Local Health District. J' <br /> (_ r <br /> Job Address v „ O Ci r Lot Size �� PM <br /> �( q� <br /> Owner's Name Address 3 � � _ Phone • —0 *3 , <br /> Contractor r AddressLicense r�:"�(N Phone` c.c� <br /> TYPE OF WELL/PUMP: NEW WELL D WELL EPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ S TEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINFS DISPOSAL rLO. PROP. LINE <br /> FOUNDATION _ AGRICULTURE\ ELL OTHER WELL PITS/SUMPS <br /> INTENDE"SE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Ty of Casing_ Specifications <br /> (-1 Public ❑ Other ❑ Delta De th of Grout Sea Type of Grout <br /> I Irrigation _Approx_ Depth I I East ace Seal Installed by <br /> 1 Repair Work Done ❑ Type of Pump H.P. State Work Dona _ <br /> Well Destruction ❑ Well Diameter Sealing Me ial (top 50') <br /> Depth__ Filler Material (Below 50.) <br /> � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted It pudic sewer is <br /> available within 200 feeLl <br /> Installation will serve: Residence�Commefdal ther <br /> Number of livwg units: _ Number of bedroo <br /> Character of soil to a depth of 3 feet: Wailer table depth <br /> SEPTIC TANK ❑ Type/Mfg � Ca.adty No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of O,is/posal <br /> Distance to nearest: Wel; 0 Foundation 5_41/L <br /> ' Property Line <br /> LEACHING LINE D No. & Length of lines_ .- Tgsaj length/size <br /> FILTER BED ❑ Distance to nearest; Wall oundationProperty Line 0 <br /> t r/ <br /> SEEPAGE PITS I I Depth Size u Wer _. <br /> SUMPS Ll Distance to nearest: Well ndation r ProPeM Line <br /> j DISPOSAL PONDS ❑ <br /> I hereby candy 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 District. I i <br /> Home owner a licensed agent's signature certifies the following: "I cartify that in the performance of the work for which this permit is issued, 1 shelf not <br /> employ any person in such manner as to become subject to workman's compensation laws of California-"Contractor's hinng or sub-contracting signature <br /> certifies the following: "I certih-that in the performance of the work for which this permit is issued,1 shall employ parsons subject to workman's compares <br /> tion laws of California." <br /> The epplrar�[{y/L�I�m��us�t�call all require inspections. C ptete drawing on rreev�Yrye�side. <br /> 1, ,(c <br /> Signed Tijde: bx_y ' '�L Date. <br /> FOR DEPARTMENT USE ONLY l <br /> AP cation Accepted by Dere <br /> I Gmu: Inspection by Inspection by D.tte9�29/! <br /> Additional Commenttic - <br /> ❑ St♦z 466-6781 '_fl Lodi 369-3621 ❑ Manteca SM-7104 ❑ Tracy 835-6985 <br /> Applicant Return all copies to: Environmental Health Permit/Servile 1601 E. Hazelton Ave., P.O. Box 201 S1k., 1 <br /> Y^ Z t INFO AMOUNT DUE AMOUNT REMITTED SN RECEIVED BY 'LLLDATENO. <br /> ♦ EN 132r IREV_rin 51 �_I. r �!J y�� <br /> EH 14pa 1�✓ 1 __ <br />