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F± _ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCiKTON, CA <br /> Telephone (209) 466-6781 <br /> t 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 /> I 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 /> t <br /> Job Address City -tom Lot Size PM <br /> r`' <br /> I Owner's Name <br /> o U Address Op Caz em `t ``—`75� rPhone <br /> j <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEWWE L WELL REPLACEMENT C1DESTRUCTION ❑ <br /> PUMP INSTALLATIO -SYSTEM SYSTEM REPAIR ❑ - OTHER ❑ <br /> 1 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. ' �� <br /> ❑industrial ❑ Open Bottom Ll Manteca _ Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack [I Tracy Type of Casing Specifications <br /> I'] Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _-Approx. Depth [-I Eastern Surface Seal Installed by - <br /> r Repair Work Done ❑ Type of Pump H.P- State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence JZ_ Commercial _ Other <br /> ' Number of living units: 49 Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: __ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 0 I�'' Capacity / moo No. Compartments 2 <br /> PKG, TREATMENT PLT. El <br /> T -r Method of Disposal <br /> Distance to nearest: Well �4 Foundation Property Line �dD <br /> N G� <br /> r LEACHING LINE ❑ No. & Length of lines j" �' - - Total length/size D <br /> FILTER BED El Distance to nearest: '/Well ff 'Foundation~ Property Line <br /> SEEPAGE PITS i IDepth Size -/ — Number <br /> SUMPS Cl. Distance to nearest: Welles Foundation 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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. n iup, <br /> Home owner or licensed agetit!s signature certifies the following: "I certify thatrin the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as tc;become subject to workman's compensation-laws of California.' Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that i6 the performance of the work•for which this permit is issued, I shall employ persons subject,to workman's compensa- <br /> tion laws of California-" <br /> i The applicant must call for all required inspections. Complete drawing on reverse.side <br /> 49 <br /> Signed X <br /> a Title: ? Date: .2 <br /> } f • F R ART USE ONLY ' r / <br /> Application Accepted by Y ' 'Date 6 Area; < <br /> Pit or Grout Inspection by ► Date /2 Final Inspection by Date <br /> Additional Comments: 'I a -a/ y - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/.Services'1601-.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-2-4 EH 14-26 IR}V.i in 51 C Z� / �� / / rs' ' ✓L'� C}(�y'�`�j, <br /> R- <br />