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APPLICATION FOR•PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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 herelmdescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. r, l <br /> t. a _ <br /> Job Address � r- �irf f/l�xs City�� �Lot�Sizeif <br /> Owner's Name / Address Phone 7 S <br /> ` -�� <br /> Contractq I' ri+'t (A dress <br /> 'u <br /> _rte J I 4_,Llcens -2 No. aa� Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1 WELL..REPLACEMENT ❑" DESTRUCTION O <br /> PUMP�INSTiALLATION L7 1 SYSTEM 1t4� 1R' 1 D:.. g OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _._'DISPOSAL FED. PROP. LINE , <br /> FOUNDATION AGRICULTURE WELL OTHEIR WELL, — PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! <br /> Dia. of Well Casing <br /> i C Industrial ❑\Open Bottom G Manteca Dia. of Well�`Excavation `l 9 <br /> -.� <br /> ❑ Domestic!Private LJttof Casing Pack ❑ Tracy � Type n9 7! Specifications <br /> ❑ Public ❑ Othe"'- C Delta I Depth of Grouut SI _ "` ' Type of Grout— <br /> C Irrigation _..�pDrox. Depths LJ Eastern Surface Seal Installed by <br /> Repair Work Done C Type of Pump H.P. Work Done �— <br /> Well Destruction L� Well Diameter /S/ealing Material toop.50') <br /> Depth ? _ Ilar Material�kiow 50'1l----­/-- <br /> TYPE <br /> 0'1__- J-- -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION :REPAIR/ADDITION =1 DESTRUCTION-111(No septic system permitted if public sewer is <br /> I -available within 200 feet.) <br /> � <br /> Installation will serve: .Residence Commercial_ Other <br /> Number of living units:-_I-- 'Numbaodrooms.�Character of soil to a dept/h of 3 feet _ Wter table depthSEPTIC TANK irT Type/Mfg _ - Capacity Q' _ No. Compartments <br /> PKG: TREATMENT PLT. Method of Disposal <br /> i <br /> I Distance to nearest: Well--A 6 Foundation _L_ Property Line . <br /> LEACHING LINE ?la'No. &Length of lines __ U_ .--. Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well, Foundation Property Line _ Zi <br /> SEEPAGE PITS hT Depth 33 umber—., +� <br /> SUMPS LJ Distance:to nearest: r Well 1�O .._ Foundation /0Property Line <br /> DISPOSAL PONDS �:1 I <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 /> rubes 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 to workman's compensa- <br /> tion laws of California." I i I <br /> The applica ust call for raqu•ed inspections. Complete drawing ,on reverse side. <br /> - ._ -- -�- - _r- <br /> Signed Title: Date: <br /> FOR DEPA TMENT USE ONLY <br /> --- plication Accepted"b — - -- « •....- -. _ Data 27 .. ..,.-O plea_"`[J �- <br /> it rGrout Inspection by L Date 7)_L final Inspection by � <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 363-3621 Ll Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i t r. <br /> 1 <br /> I IFEE NFO COUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT`NO, <br /> EN 1321(REV. ,•-� <br /> EH 1426 [S.•=a -_.... /17 M1 . <br /> r.+'.-•"�'�"��"ice i <br />