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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT X. <br /> 1601 E.. HAZEL T ON-AVE., STOCKTON, CA <br /> +` Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'f 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 /> �N r� <br /> Job Address l �-�'� � �� City � Lot Size � k -I' PM <br /> Owner's Name•sk o! f��-S�/�. Address l� a �*` '�� Phone <br /> al , pd'Y`' °�/ Phone . S / <br /> Contractor Address A ��� License No. <br /> TYPE OF WELL/PUMP: '-NEW WELL ❑ E WELL REPLACEMENT ❑ DESTRUCTION [I-, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' <br /> M DISTANCE TO NIAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. f PROP. LINE Y <br /> FOUNDATION AGRICULTURE;WELL -r OTHER WELL '' S'PITS/SUMPS._ <br /> ti INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA_TION$,- } <br /> ❑ Industrial EDOpen Bottom ElManteca E Di'. of Well Excavation` k~ :w'�`---iiia -of-WefNC-acing <br /> LIDomestic/Private ElGravel Pack El Tracy S Type of Casing Specifications <br /> M Public } l=1 Other a f-1 Delta I Depth of Grout Seal Type of Grout <br /> 1.1 Irrigation Surface.Seal Enstalled by <br /> Repair Work Done ❑ Type of Pump H.P. r State Work Done <br /> Well Destruction ❑ Well Diameters Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC:WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ESTRUCTION I 1 INo septic system permitted it public sewer is <br /> = - available within 200 feet.) <br /> Installation will serve: Residence— Commercial_�� Other <br /> Number of living unils: Number of bedrooms 6-7-k eO$& <br /> . t <br /> Character of soil to a depth of 3 feet: 1�9Dd Water table depth ji6 <br /> ._SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 'PKG. TREATMENT PLT. ❑ ` Method of Disposal <br /> r <br /> I Distance to. nearest: Well Foundation Property Line f <br /> LEACHING LINO -42(—No. & Length of lihes ,� Total'length/site 4 <br /> FILTER BED ❑ Di`stance to nearest: Well I-CC) ♦♦ Foundation /� a T Property Line ria <br /> e I <br /> ,-SEEPAGE PITS Depth �?S Size -A'a e. Number <br /> SUMPS P., ❑ Distance to nearest: Well�IC6' foundation oed 7a"' Property Line <br /> DISPOSAL PONIDIS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,sand <br /> rules and regulations of the San 3Joaquin Local Health Dt%trict.Homeownerowner or licensed agent's signature'cefi-tifies tfie following: �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 Cblifornia."Contractor's hiring or subcontracting signature <br /> 'certifies the following: "t 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 Cali#ornia." -F s <br /> The applicant m all for all r uired inspections. Complete drawing on reverse side. j <br /> Signed,k Title:�1?4 Z_W. Date: G 3 <br /> e <br /> t FOR DEPARTMENT USE ONLY <br /> Application Accepted-byy--- . Date �� Area ( y <br /> Pi r Grout Inspection by Date . Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 1 <br /> I <br /> FEE <br /> a <br /> i <br /> INFO AMOUNT DUE '• AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. _ <br /> 1 <br /> +..EH 114 IREV.1 i s) <br /> f' <br /> EH 14-28 ' <br />