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t <br /> 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. qq p cAIa �j _ 7 <br /> Job Address -73 W. L�CG r'Z ACX - Wel City Lot Size PM <br /> Owner's Name r Address kk � Phone (O 117 <br /> tg*Contract �Gi��1 - Address 0p^ ° � 7E' 7�License No. �ZV27-(P Phone EQb 1 <br /> TYPE OF WELUPUMP:- .- "- NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> J, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> —DISTANCE TO NEAR T:'SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE <br /> J,4 6 7 IFOUNDATION AGRI L OTHER WELL PITS/SUMPS <br /> ii t �'� i k c• IN <br /> ...:.t r <br /> INIT�NDED USE �TYP..E OF WELL PROBLEM AREA CONSTRUCTIOS TIONS <br /> O-Industrial t-- ❑ Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> NOtOther <br /> ❑.Domestic/PriO-Gravel"Palk. 4t0'`Tracy R Type of CasinSp tions <br /> OPublic i ❑ belts I Depth of Grout Seal Type of Grout <br /> ❑ Irrigation Tfpprox. Depth ❑ Eastern Surface Seal Installed by <br /> r <br /> Repair Work Done ❑ Ty e\f Pump H-P. State Work Done <br /> Well Destruction - Cl---Well Diameter's Sealing Materi6l_(top•50') --- --- <br /> Depth_.` Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:--NEW-INSTALLATION '"'REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> vailable within n 2feet..)' <br /> iJ Q �C <br /> Installation will serve: Residence_ Commercial Otherof <br /> „$ L• <br /> Number of living units: Number of edrooms (J aQ wl�p f <br /> r <br /> Character of soil to a depth of 3 feet: -.-Water table depth <br /> SEPTIC TANK 0t -Type/Mfg r r Capacity_/&_O_� No. Compartments <br /> PKG. TREATMENT PLT.❑ i Method of DiTosal <br /> Distance to nearest: Well 1400— Foundation Z— Property Line .r <br /> / t <br /> LEACHING LINE & Length of lines Total length/size X <br /> t rS <br /> t FILTER BED ❑ Distance to nearest: � � o Well nFoundation-41) I Property Line <br /> SEEPAGE PITS ❑ Depth SizeY 1 Number = <br /> i SUMPS ❑ Distance to nearest: Well El `r ' Foundation Property Line 41 <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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation 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 shall employ persons subject t6-workman's compensa- <br /> tion laws of California." <br /> The applicant t call for all r wired inspections. Complete drawing on revers�se•` ` <br /> Signed X Title:�l t r Dater C / <br /> i <br /> FOR DEPARTMENT USE ONLY �( <br /> Application Accepted by Date-/V2- /v Area <br /> Pit or Grout Inspection by Date Final Inspection by 414 Date` !,�� <br /> Additional Comments: <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-.'6ox-2009,Stk:7CA 95201 '- <br /> FEE AMOUNT DUE AMOUNT'REMITTEO -'CK* " RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> 11 <br /> + EH 24 tREV.r�R5) <br /> t EH 14-26 ' <br />