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Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ' <br /> j Telephone (209) 466-6781 7 <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 /> o l <br /> Cit �1 <br /> phis y Lot Size � ' �' �� PM <br /> Job Address p 1 <br /> Owner's Name <br /> ti\G�'�Q-V��. tiaf$V Address LAP.f� JAYS P('1v�riQ Phone s2� � )3 <br /> ' I <br /> Adds3 » " f ( � N � � S Phote� Ls- 7 <br /> Contractor-Gr— x „G . � 2�}� <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 /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <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 Packi ❑ Tracy Type of Casing Specifications <br /> ['l Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth i 1 Eastern Surface Seal Installed by - Q <br /> Repair Work Done Ll Type of Pump i H.P. State Work Done <br /> Well Destruction ❑ Well Diameter', T Sealing Material (top 501 <br /> Depth Filler Material (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted it public sewer is <br /> I <br /> available within 200 feet_1 <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms r # <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ .. Method of Disposal` <br /> Distance to nearest: Well Fpundation Property Line <br /> LEAC E O No. & Length of lines I"" _ Total length/size <br /> FILTER BED ❑ DSstance to nearest: Well Foundation { t Property Line <br /> S AGE PITS i I Depth Size -+ lumber <br /> QP50SAL <br /> L1 Distance to nearest: Well oundationProperty Line <br /> 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, and <br /> rules and regulations of the San Joaquin Local Health District. 7 <br /> Home owner or licensed agent's signature certifies the following: "t certify that in the performance of&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 C6fornia." 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." <br /> The applicant must tali for all requited inspections. Complete drawing on reverse-sida.' <br /> Signed X r� o. Title; Date: <br /> I F ,DEPARTMIENT'.USiE ONLY , <br /> t •ek, � ` <br /> lApplication Accepted by `�C' ' Date ~ Area ! f` <br /> Pit or Grout Inspection by <br /> r R Date 'Final-Inspection-by Date <br /> Additional Comments: \ ; <br /> F ❑ Stk 466-6781----�O Lodi 369-3621 ❑ Manteca 823-7104 4 O Tracy 835-6385�;.� , <br /> F ApplicantReturn all copies to:.Environmental.Health Permit/Services 1601 E-.-Hazelton-Ave.-,-P.-07 Box-2009-Stk-7CA 95201 "' <br /> FEE MOUNT DUE AMOUNT REMITTED KZ75RECEIVED BY DATE PERMIT'NO. <br /> rC INFO <br /> f +.EH 124 IREV.5 i n 51 7&0[ � O �� `b .?�, ,� � Q <br /> EH 14-4-28 -__L 5�7 <br />