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M <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (2491 466-6781 <br /> j 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 /> 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 /> � <br /> Local Health District. <br /> Job Address 1e5 rte=' City Lot Size ' PM <br /> r,[,'�rj'e { t�SP Address /} _LL <br /> t Owner's Name '1 b Phone <br /> 1 Contractor / � eV- Address r S /�`a0ye License No. + <br /> Phone—4-9-92-2 <br /> TYPE OF WEAL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑v DESTRUCTION l <br /> PUMP INSTALLATION Cl SYSTEM REPAIR: ❑ �­OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK "a SEWER LINES P DISPOSAL FLD. PROP, LINE <br /> FOUNDATION - AGRICULTURE WELL + OTHER WELL PITS/SUMPS <br /> rd <br /> ISI{ INTENDED USE f TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '� ✓` <br /> I ❑ Industrial .I. i]jOpen bottom L1Manteca Dia. of Well,Excavation- Dia. of Well Casing <br /> 1 ❑ Domestic/Private ❑ Gravelf Pack ❑ Tracy Type-of Ca-sing S Pecifications <br /> - <br /> 9 g°� <br /> Type of Grout <br /> F1 Public ill'Other C1 Delta Depth of Seal <br /> YP <br /> I i rox. Depth 11 Eastern Surface Seal Installed by - - <br /> I 1 Irrigation I ---APP <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done - <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> r Depth -Tiller Material.(Below 501 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 ReAlTVADDITION'K 'DESTRUCTION (No septic system permitted if public sewer is <br /> f ti available•wittiin-200 feet.) <br /> Installation will serve: Residence x_. Commercial_ Other <br /> Number of°living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ; a i r_Water Mable depth <br /> SEPTIC TANK ❑ Type/Mfg acity No._C6mpartments <br /> lQ�-a� <br /> PKG. TREATMENT PLT. ❑ W1, Method -?,AofDisposal f <br /> f u Distance to nearest: _ / O Foundation, 'TD Property Line_... _ <br /> I 1A 0 <br /> LEACHING LINE $I No. & Length of lines Total length/size t, <br /> IQ — <br /> FILTER BED' ❑ Distance to nearest: Well /'(i�D Foundation IProperty Line- <br /> SEEPAGE PITS 11 Depth i S_Size Number <br /> SUMPS L-1 Distance to nearest: WeH Foundation-n""" ""'Property Line <br /> r DISPOSAL PONDS ❑ <br /> 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 Di'stri'ct. x <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 therformance of the work fo <br /> e pr which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." t 4 <br /> The applicant mus callAr all required in tion omplete drawing on reverse sided <br /> ..b —�— <br /> Signed X Title: Date: <br /> i FOR DEPARTMENT USE ONLY <br /> L/ <br /> Application Accepted by Date 6 ' Area <br /> +' <br /> Pit or Grout:lrtspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> k ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., Pay P0. Box 2009, Stk., CA 95201`1 <br /> !! FEE AMOUNT DUE AMOUNT REMITTED CK H, RECEIVED BY (DATE PERMIT'NO. <br /> t INFO <br /> iY <br /> EH 14.26 L v <br />