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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone Q09] 466-6781­-1------- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J (Complete.in Triplicate) <br /> Application is hereby mad 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. l )v_ l <br /> Job Address ,,/" City � Lot Size�7� e� V PM <br /> x Owner's Name Address Phone <br /> r - <br /> ' Contractor Address License No. Phone_ <br /> TYPE OF WELT/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 h <br /> INTENDED 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 Cl Other ClDelta�w Depth of Grout Seal "Type of Grout . <br /> I I Irrigation ..Approx. Depth I <br /> Eastern .- Surface Seal-Installed by. <br /> Repair Work Done 0 Type of Pump. H.P, � it State Work Dane <br /> r Well Destruction 0 Well Diameter Sealing Material (top 50') <br /> Depth Filter Material 48elow_50=1� ^� <br /> (�,,-,712YPC OF-SEPTIC WORK:F NEW INSTALLATION -REPAIR/ADDITIO.N I I DESTRUCTION f I (No septic system permitted-if-public'sewer is <br /> available within 200 feetA <br /> Installation will serve: Residence Commercial , .OtheO " <br /> Number of living units: Number of bedrooms_— l `! <br /> Character of•soil to a depth of 3 feet: - I ' -Water table depth <br /> 6EPTIC-TANK ❑ Type/Mfg /LJ t=' Capacity NoICompartments <br /> I �. rT"._�1 i.. <br /> f / P1CG. TREATMENT PLT. Cl t r f t Method of Disposal <br /> i Distance to nearest: Well'_ „�� Foundation _ .(._.___ Property Line r <br /> LEACHING LINE . 0 No. lf, Length of lines i ' 4 _a Total length/size f <br /> F <br /> FILTER BED.' ❑ Distance to nearest: Well Foundation'' ;Property Line <br /> SAGE PITS. I I 'Aepthr Size___..__�_�__7_. "�Sl.__• Numier_ N< <br /> E SUMPS ❑ Distance to nearest: Well _ ! Foundation Jro�. Property Line ' <br /> A OSAL PONDS p. <br /> 1-hereby certify that I have prepared this application and that the work will be done ir'racco tlance with-San Joaquin county ordinances, state laws, and <br /> f rules and regulations of thAan Joaquin Local Health District. " 4 1 <br /> I 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`rrwnner as to become subject.to workman's compensation laws of California.".Contrac4s hitiitg,or'sub-contracting signature, <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic ustcall for all wired inspections. Complete drawing on reverse side. <br /> Signed X Title: _ A Date: <br /> FOR DEPARTMENT USE ONLY �. <br /> Application Accepted bDate r /+.F' Area `/ <br /> 2- <br /> fsfs y <br /> ' Pit or Grout Inspection by � � Data Final inspection by�� <br /> Additional Comments: <br /> C1 Stk 466-6781 --D-Lodi 369-3621---*­0❑ Manteca-823-7104' -0 Treay `835-$385" <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> } <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVEDpY DATE PERMIT.'NO. <br /> INFO CASH �j •� <br /> - +.EH 53-24 iRM 1 r H 5f -¢() Ufl �iQ0 <br /> t EH 14-29 F <br />