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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES"1 YEAR FROWDATE 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 descnd.;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 /> j Local Health District. i <br /> Job Address__ Z e"'� I City'—Lf Lot Size Y PM <br /> Owner's Name . Address :" - Phone"— w <br /> ti <br /> Contractor,N 1�1__fr)f�lkk_�Address \a�50 F LQ - _ License No.4Zqn_Phone- <br /> TYPE OF WELL7PUMP. NEW WELL' CI"' '-�- rtiNE L REPLACEMENT ❑ DESTRUCTION ❑ ' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ _ OTHER ❑ �^ <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS F <br /> ,JNTENDED_USE.T-Y_PE_OF-WEL.L—P-ROBL-EM-AREA--CONSTRUCTION SPECIFIGAT•10NS�r'6 •' - <br /> - — I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i L3 Public iJ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> f' ❑ Irrigation __Approx. Depth ❑ Eastern Surface Seal Installed by_. <br /> Repair Work Done Cl Type of Pump H.P. State Work Done <br /> 1 <br /> Well Destruction Cl Well Diameter _ Sealing Material (top 501 <br /> f Depth r-Filler Material (Below 501 <br /> P y <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION PAfR/ADDITION ❑ DESTRUCTION C (No septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will serve: Residence IL-1--commercial t Other <br /> Number of living units: �_ Number of borooms <br /> Character of soil to a depth of 3 feet: DRY Water table depth __ <br /> SEPTIC TANK Type/Mfg _ 2 Capacity-C No. Compartments <br /> PKG.TREATMENT PLT. L2 gj- C Z)NCet; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line -E' <br /> 1DD <br /> LEACHING UNE Q__No. & Length of lines rT6tal1en' th/size '*-Z) <br /> FILTER BED G Distance to nearest. Well. �+ Foundation Property Line <br /> SEEPAGE PITS N4 pth _ Size Number } }} <br /> -Y- <br /> SUMPS C Dista nce'to`'nearest: Well' Foundation _.,Property Line r <br /> DISPOSAL PONDS i❑ <br /> f - <br /> I hereby,certify that I'll prepared this`application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules andxegulations of.the San Joaquin Local Health District <br /> Home owrier or licensed agent's signature certifies the following: "I certify that in the performance of the work for Which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Califomia."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 iiiued,'f�shall employ persons subject to workman's compensa- <br /> tion of Cal'rfor <br /> The applican, t call f all r �uiremspecl ..�ploje drawing on reverse side. <br /> Signe Tltle: D. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by __. -r Date Area <br /> J n •-- fJ <br /> - <br /> Pi j or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Ll Stk 466-6781 :]..Lodi 3159-3821 O 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 95201FEE ; <br /> INFO AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED By. DATE PERMIT'NO. <br /> +erilazy rAev_I/es) t °( <br /> . EH 1428 _ ]' V' <br />