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`APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> j Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 1 <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 ��►Z-�S ' /L.4 1/CEfr! '�� City ae-A7'� Lot Size G PM �t <br /> �//�� f <br /> Owner's Name �i!>vs f��lsarl� f Address C EsPQ���ZZW Phone <br /> Contractor .4_1.. E Address [4 C),' 1ST <br /> a11-Z:Kr1 &2�!c{_.Q. License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> iNKNDED USE-- —TYPE OF WELL— -PROBLEM AREA--.- CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ­.Approx. Depth { I 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 561) <br /> Depth t Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L] DESTRUCTION i I [No septic system permitted if public sewer is <br /> r I / available within 200 feet./ <br /> Installation will serve: Residence Ct <br /> r j -fzL/ <br /> ommercial Other <br /> Number of living units: .`?Number of bedrooms _ l <br /> Character of soil to a depth of 3 feet- p C.' =^w '` Water table depth t <br /> SEPTIC TANK ❑ Type/Mfg :6 �-�. s Capacity No. Compartments <br /> t PKG. TREATMENT PLT. ❑ �- Method of Disposal <br /> Distance to nearest* Well 1AA0 Foundation 0*417 Property Line C� <br /> MT <br /> LEACHING LINE } No. &-.Length of lines d�'8 Total length/size C <br /> FILTER BED `0f istance to neatest: Well Foundation-20.lor-7 Property Line <br /> SEEPAGE PITS I ) Depth 10 Size 1Ano ..Number 1 <br /> SUMPS Distance'to neamst:, _Well t 1.5-0 }+ Foundation' Properly-kine <br /> ' 'DISPOSAL PONDS ❑ ti <br /> f I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <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 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 <br /> The applicant must tali for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Dater <br /> i c <br /> ZjEP.A1.1TrI0ENT USE ONLYApplication Accepted byDate l 6 Cf F Ara ��a <br /> it t <br /> Pit or Grout Inspection by Date Final Inspection by r o If <br /> f' <br /> a . <br /> l Additional Comments: <br /> t ❑ Stk 466-6781 0 Lodi 369-3621 ❑ 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 95201 <br /> t <br /> FEE <br /> y l INFO x AMCK <br /> OUNT DUE — AMOUNT REMITTED" CASH RECEIVED'8Y' '" DATE PERMIT-No,- .� <br /> +.fH13-24U;EV,r/H51 [ <br /> EH 14.26 <br /> ' x <br />