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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 1 Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1­YEAR FROM DATE.ISSUED .IFS <br /> _ (Complete in Triplicate): °;u�. . �oi3;.7o' bn�.:�nll;u r <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. , n <br /> Job Address <br /> $rlleJb e t City�rQ2y_ Lot Size PM <br /> Owner's Name ?,�Y�i+rl4 Address "i= `i' &IQ,l eb -± Phone "r <br /> Contractor 00d+ f-6 logr?c _. Address d1 JVJ7G ,� License Nnr ,?t4`j � Pfione'' <br /> TYPE OF WELL/PUMP: .NEW WELL.-C] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK ._. _ _ __ SEWER LINES' DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL__ PITS/SUMPS _ <br /> INTENDED USE TYPE,OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial D Open Bottom _❑ Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack- , `_L}Tracy- �, Type of Casing Specifications <br /> C'. Public L Other ❑ Delta t Depth of Grout Seal _—_._� - Type of Grout <br /> ❑ Irrigation _-_Approx. Depth ❑ Ea�fem,'A Surface Seal Installed by- <br /> <, Repair Work Done C Type of Pump --__ H,P14 State Work Done_ <br /> Well Destruction L Well Diameter Sealing Material (top 50') <br /> Below,50'-) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION L DESTRUCTION ❑ANo septic system permitted if'public sewerlis <br /> - .- k i r r l*a 'available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other #.. lrr �,._ �, ,.. rte., �• � r <br /> `- Number o hvi'ng units, / Number of bedrooms ` <br /> Character of soil to a depth of 3„feet: __,� �d Gam- w - -� ---� - Watertable-drip <br /> SEPTIC TANK �' Type'1Mfg,' _�� �i•�” Capacity—,41" No. Compartments-- _ l <br /> PKG. TREATMENT PLI. Method of Disposal + _ <br /> Distance to nir"es�:";�j�VaCell Foundation+��'"" - '=Prop Property Line �— <br /> LEACHING LINE I f t <br /> 1�1 C No: & Length of lines t a X Total length/size <br /> FILTER BED t >/• Dist+ance'to nearest: Well/;Foon 33"�7�Property Linea <br /> ... �. f' f1 :ate....-•----•-•�.-- �.----.. ____.._T..�..`..,....=-k, i 1 <br /> SEEPAGE PITS ` L l Depth Size Number <br /> I SUMPS _ r Distancelto nearest:, Well r Founbatfo)t Property Line I <br /> 11 t <br /> DISPOSAL PONDS ' L 1 <br /> I hereby certify that/,have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations'of'the San Joaquin Local Health.District.. i E <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 rot <br /> I employ any person in such manner as to become subject to workman's compensation laws of California."'Coritraetor s hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is 4ssued,I shall employ persons subjec to workman's compensa- <br /> tion laws of California-": <br /> The applicant must call for all re red linpeCtiom. Complete drawing o_n reverse side. <br /> -,; _,++::..,..K..w-...•<-...t,..+..- ,r �" ate-_ <br /> Signed X__ ��__4 _..Title: �" -- Dane: T <br /> FOJRDEPARTMENT USE ONLYi19 7 <br /> Application Accepted by 3 f.. `%'f'�/ Date <br /> r --- t 1 <br /> Pit or Grout Inspection by I f € Date Final Inspection by Data <br /> f Additional Comments: <br /> L Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 623-7104 ❑ Trac 835-6385 'f f <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 t <br /> INFO AMOUNT DUE AMOUNT REMITTED tCK 9 i'• RECEIVED BY DATE PERMIT NO. <br /> HI <br /> E"+ ' <br /> E+4 <br />