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APPLICATION FOR PERMIT <br /> 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p <br /> 1601 E:'HAZES i ON. AVE., STOCKTON, CA <br /> Telephone 12091"466-6781 <br /> F <br /> PERMIT EXPIRES TYEAR 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'iJoaquin 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. I <br /> Job Address -57 Chit Size PM <br /> Owner's Name �F._� [_-t Address +(�fv-7"(� /��G�. �� Phone , <br /> Contracto�az— vV, Address +?(Dosox License No. Z 3 Phone 4-66 16 <br /> TYPE OF WELL/PUMP: : I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> h <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— PITSISUMPS <br /> � - l <br /> INTENDED USE # TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind trial O Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing •` <br /> j <br /> omestic/Private i❑ Gravel Pack ❑ Tracy Type of 'Casing Specifications <br /> 1-1 Public IF1Other Cl Delta Depth of Grout..Seal` Type of GroutJr <br /> '+ y <br /> I I Irrigation s _ApF& Depth �J 1-E' stern Surface Sea`installed by' <br /> Repair Work Done IBS Type of Pump 1k-"H-.P1- State Work Done 604 Ldl Al <br /> Wel! Destruction ❑ Well Diameter Sealing Material (top 50') _ 1 <br /> Depth Filler Materia! {Below 50') <br /> f ' -- <br /> TYPE OF SEPTIC WORK: ": NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is <br /> ° available within 200 feet.) <br /> Installation will serve: Residence,_.+Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1<�� Water table depth <br /> SEPTIC TANK ❑ ! Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ' Distance to nearest: Well ''Foundation Property Line <br /> k <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ ' Distance to nearest: Well Foundation Z Property Line <br /> ! <br /> V-7 <br /> SEEPAGE PITS I'] : Depth Size • Number <br /> SUMPS ' y}' ❑ Distance to nearest: Well Foundation y Property Line <br /> DISPOSAL PONDS ❑ `� <br /> I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin county ordinahces, state laws, and <br /> rules and regulations of the San Joaquin Local Health DoMfict. dV <br /> Homeowner o i ensed a is signature ce les the foil g: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any arson in such m ner as to be a subje to rkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t following: ' pertif that in th a of a work for which this ermit is issued, I shall employ persons subject to workman's compensa- <br /> tion lawof California." 1 j <br /> The app cant mu or req d Co drawing on side. s 1 a� <br /> Signed X Titfe: '� Date: /( - ye- <br /> � '1 <br /> R DEPARTMENT USE ONLY t <br /> Application Accepted by I 7 Aare , Date Area <br /> Pit or Grout Inspection by Date Final Inspection by!�_7' . Data <br /> --"'Additional-Comments: -- -v---- <br /> ❑ Sik-,466-6781 j\-0-Lodi 369-3621 ❑ Manteca 523-7104 0 Tracy eW5-6385 *�, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton`Ave'.,'P.O.Box 2009, Stk., CA 95201 <br /> 6 <br /> INFOEE OU�--NT DUE AMOUNT REMITt GASH RECEIVED BY DATES PERMIT-NO. I <br /> ♦.EH 13-21(REV.1/H51 irte' <br /> EH 14-26 {J V - <br /> .h- <br /> 'a <br />