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APPLICATION FOR PERMIT <br /> n. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. <br /> Job Address <br /> SSS A). 6/a*07-bAsE- <br /> !,� �,, City Lot Si�zze- PM <br /> Owner's Name47696 Address 2JaC-rte /� ,�c[�. Phone <br /> r ContractsA-TU/YI �k"/W/W7�Address License Ncf0080A Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X MDIJlW4JX-7 AIRU., <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IndustriaN-MFNi00r4g� Open Bottom• ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/PrivaWt'-L' ❑ Gravel Pack .} ❑ Tracy Type of Casin ' Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal L S a� <br /> p � Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC W NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic stem permitted if public sewer is <br /> * available ithin 200 feet.) <br /> A <br /> Installation will serve: Rest nce_ Commercial_ Other <br /> r <br /> Number of living units: mber of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to of <br /> I Foundation roperty Line <br /> LEACHING LINE ❑ No. & Length of lines T al length/size <br /> FILTER BED ❑ Distance to nearest: Well Faun Property Line <br /> SEEPAGE PITS ❑ Depth Size bar <br /> SUMPS ❑ Distance to nearest: Well Foundation perry Line <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, andp <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 subcontracting 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." <br /> The applicant must call for all required inspections. Complete drawing o averse side. <br /> Signed Title: 41La Date: <br /> X _ II0 86 <br /> A5EM USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout lnspec o yam' Date Final Inspection <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> � ] I <br /> IAEv.,,651 3�� 3s $foo IV p F& isOR <br /> zz- <br /> '� z� <br />