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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 /> (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 /> 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 /> ' Job Address �l D J' Y Lt� City J Lot Size V ? PM <br /> KL�'I LLifCvn . L/ <br /> Owner's Name �. ,/� f�Tf Address tt o S^ O� <br /> %+ Phone <br /> r l �r U� m <br /> Contractor Address 1�-► License No. Phone <br /> -- <br /> T"TYPC'GF'WEEE/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l� <br /> i FOUNDATION i `: AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL -,,PROBLEM" AREA CONSTRUCTION SPECIFICATIONS f! <br /> ❑ Industrial El Open Bottom ❑ enDia. of Well Excavation Dia. of Well Easing ` <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy.•, _ Type of Casing a Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth-of Grout Seal <br /> P Type of Grout ,- <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern; Surface SeaYlnstalled by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler(Material (Below 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITT ❑ DESTRUCTION ❑ (Nb'septic system permitted if public sewer is, <br /> ° available within 200 feet.) , <br /> / t <br /> Installation will serve: Residence K Commercial _ Ot er - <br /> l Number of living units: Number of bedrooms 2' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T e/Mf <br /> YP 9 � 4 Capacity' ��-� `-• No. Compartments <br /> PKG. TREATMENT PLT. ❑ '+' i <br /> �,/� +Method of Disposal, <br /> ` Distance to nearest: Well f Foun anon1`4aPrope <br /> Line ZOO <br /> lry! LEACHING LINE No. & Length of lines T al length/size <br /> >' <br /> FILTER BED ❑ Distance to nearest: Well� .If)CZ= Foundation Property Line 1_/_J_ <br /> SEEPAGE PITS ❑ Depth 2 ,Size tit_ Number 1 <br /> SUMPS ❑ Distance to nearest: Well 4sy Koundation O Property Line ! Q T <br /> ` DISPOSAL PONDS ❑ ^- <br /> I hereby certify that I IrTve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatiQQf' he San Joaquin.Loyal Health District. <br /> Home owner or li=pe'tl t' sin +� <br /> 1 9@tL� galore certife the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person irisine manner as to become subject to workman's compensatioq,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 stall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica must call for II required inspections. Complete drawing on reverse side. C/ <br /> Signed X Yu5 Title: G-&Aeol .ti Date: l J CtC <br /> 1 <br /> i — <br /> `' F DEPARTM_E}NT USE ONLY Q <br /> Application Accepted by y """� Date 1 Area <br /> Pit or Grout Inspection by Date "! <br /> 9_g-ai Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca( 823-7104 ❑ Tracy 836385 <br /> Applicant - Return all copies to: Environmental Health Per 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CAS µ RECEIVED BY DATE PERMIT NO. <br /> EH; <br /> 3-211REV.i 451 �'J . <2,3 _� /3/ 1`9 <br /> V <br />