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:1-1i <br /> k <br /> APPLICATION FOR PERMIT'SAN JOAOUIN LOCAL HEALTH DISTRICT 1 . <br /> 1801 E. HAZEL WIN AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> " PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> " Application B hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This application is <br /> 'minks in compliance with San Joaquin County Ordinance No.549 for sowage or No.1862 for wewpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. t,1 p� 119*s­oX- <br /> Job Address •`r �y"� �J City t_=1�—i�=��Lpot�Sixe�00 it <br /> OwnerWPM <br /> Name <br /> {A�_�_r ^ Address �� J� 1 2/��� Phone <br /> Contractor Address___ License No. Phone <br /> } TYPE OF WELL/PUMPJ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS <br /> _ <br /> • INTENDED USE TYPE OF WILL PROBLEM AAEA CONSTRUCTION SPECIFICATIONS /v <br /> ❑IMustrial ❑Open Bottom ❑Mamoca Dia.of Well Excavation Dia.o1 Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing _ Specifications <br /> S ❑ Public ❑Other ❑ Delta Depth of Grout Seal ___ Type of Grout <br /> ❑Irrigation —Approx. Depth ❑ Eastern SurfaceSeal Installed by r- <br /> Repair Work Done [I Type of Pump M.P. State Work Done— V <br /> 1 Well Destruction ❑ Well Diameter Sealing Material(top 501 -- <br /> S" j Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION('❑ DESTRUCTION i7 INo septic system Permitted if public sewer is <br /> •ski• �J i available within r }I �/ <br /> Installation will serve: Resident) Commercial_. llOther_ �ok �.4e* ( Q I <br /> Number of living units:4— N,,ber ofdrooms Y O / <br /> Character of soil to a depth of 3 f)et�� __Water table depth \�/J1 <br /> SEPTIC TANK X Type/Mfg C Capacity o No.Compartments <br /> PKG.TREATMENT DLT.❑ / 1 ^/ Method..of Disposal <br /> j Distance to nares.. Well + 0b Foundation 0 Propeny LinP,&,t]_ <br /> rVA <br /> LEACHING LINE D[ No.8 Length of linos ��.y�s� , I length/size �. <br /> FILTER BED ❑ Distance to nearest: Well_t Ool Foundation_+o_ Property Linen+ <br /> SEEPAGE PITS Depth Slze— M E h Number / <br /> SUMPS ❑ Distance to nearest Well_ILnL Foundation_ZS` _ Propeny Line�g_ \/ Z <br /> DISPOSAL PONOS Z) <br /> DISPOSAL <br /> 1 hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,'state laws, and V <br /> rules and regulations of the San Joaquin Local Health District. I shall not <br /> Home owner w licensed agent's signature cartifies the following: "I certify that in the performance of the work for which This permit is issued, <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature <br /> cenilies the fodowing:"I ceniy that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's compensat <br /> tion laws of Caldornia." <br /> The applicant must call for all required inspections. Complete drawing on reverse side <br /> '-- Date: <br /> nI Title: — ---- — <br /> signed X <br /> • FOR DEPARTMENT USE ONLY <br /> Application Accepted by �/]\ Date Area <br /> Pit or Grout Inspection _ Date D Final lnaPec ion by <br /> Additional Comments. rP p <br /> ❑ Sit, 465,6781 ❑ Lodi 3693621 ❑ Mantoca 823.71744 ❑Tracy 875.8985 - <br /> Ar.plium- Return all copies to: Environmental Health Parort/Services 1601 E. Haxalton Ave., P.O. Box 2009, SIA., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT NO. <br /> INFO <br /> • ERrl N(FUN <br /> t.1x M <br />