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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> L� 6 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. <br /> Job Address G�7S o K�_s W_L City « L to Size �� �L _ PM _ <br /> „Owner's-OwnerAddress_ 56►k�/ ,Phone ._.. ._.-.._ <br /> Qi <br /> Contractor -14 Address _._ ( License No. Phone y s t <br /> TYPE OF WELL;PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI \ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR l OTHER L <br /> 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 /> L Industrial ❑ Open Bottom I-. Manteca Dia. of Well Excavation Dia. of Well Casing <br /> G Domestic/Private ❑ Gravel Pack Li Tracy - Type of Casing - Specifications <br /> M Public l_1 Other `l;Cl Delta Depth of Grout Seal Typo of Grout _ <br /> I I Irrigation Approx. Depth `hI Eastern Surface Seal Installed by <br /> Repair Work Done 17 Type of Pump r H P. _-- .- __.- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth � Filler Material (Below 501 <br /> fYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: �_ Number of bedrooms 3 <br /> Character of snit to a depth of 3 feet: _5',�-14( Ory -__Water table depth <br /> SEPTIC TANK I-, Type/Mfg Capacity No. Compartments <br /> PKG TREATMENT PLT. L - '^ !! Method of Disposal I_ <br /> Distance to nearest: Well - Foundation t. Property Lino <br /> LEACHING LINE �Nb B Length of lines_.��L11a�_�� t Total length/size <br /> FILTER BED [l Distance to nearest: Well",5:()fi Foundation �� Property Line _ <br /> SEEP-AGE PITS I I Depth Size ._. ---- .__. I Number <br /> �.'. SUMPS 1_71 Distance to nearest. Well __ Foundation __.___— Property Line <br /> �­�.,DISPOSAL-PONDS-; C: - /t' ; I <br /> 1'hereby certify that I have prepared this application and that the work will be hone in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I �',. , <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 componsa <br /> tion laws of "California. ' <br /> _ <br /> The applicant-must call for all req 'ad inspections. Complete drawing on reverse side. <br /> /� <br /> Signed X Vt�M'../ � f I Title: ILK1x 1l,T- pate: /h ' <br /> } r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ r t `J Date -/7-4f? Area / r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> D Silk 466-6781 G Lodi 369-3621 1-) Manteca 823-7104 C) Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i ) <br /> FEE <br /> IAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE /PERMIT NO <br /> L EH 3.24(REV <br /> irn Sl �.-O - -- _ S •S� �/1 �'T/ - I <br /> _...S EH il4B !/�(� •�1, V�� -_ ,,,• <br />