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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Locai 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 /> / r <br /> Job Address 302 ,6' 1.47-M2c P City ZA?Wow Lot Size 13Z G 1 PM <br /> Owner's Name S7_Ev45,V 8. kl L'L&J Address Z� r Z-67M,126P-go, Phone M'25 <br /> Contractor y�"► �� �i5 Address /� Al C40? +�• License No. ZJZ-� Phane�rr I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> MP INSTALLATION ❑ SYSTEM REPAI ❑ OTHER <br /> DISTANCE TO NEAREST: SEPANK " '� SEWER LINES` DISPOSAL FLO. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL BLEM AREA CON RUCTION SPECIFICATIONS <br /> ❑ Industrial } ❑ Open Bottom LI of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> asing Specifications <br /> C'1 Public Ll;Other F1 Delta th of Grout Seat Type of Grout _ f <br /> I I irrigation _Approx. Depth I ] East Surfac eel Installed by <br /> Repair Work Done ❑ Type-of Pump -�H.P. State Work Done �f`} <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Cl) <br /> Depth T_`.r �FFiller Material IBe ow 50'i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION I 1 o,septic system permitted if public sewer is <br /> available within 200 feet.: <br /> Installation will serve: Residence Y_ Commercial_ Other <br /> Number of-living units: _..-I— Number of'bedrooms 4- ,_ � I <br /> Character of soil to a depth of 3 feet: ISA lu p 4 f Water table depth_15 ZC <br /> SEPTIC TANK LJType/Mfg C(5 -C Capacity—, (4[9 t) 'No. Compartments <br /> PKG. TREATMENT PLT. ❑ e-0I „ ,.� Method of Disposal C� <br /> Distance to nearest: Well Foundation 1—t-0 Property Line <br /> LEACHING LINE &"Length of lines Total length/size S1;U0 <br /> FILTER BED ❑ Distance to nearest: ­ .)Well Foundation J D Property Line_--3„.Q_.— C <br /> SEEPAGE PITS ;rk %I Depth Size _ " Number I ' <br /> SUMPS Distance to nearest: Well Foundation Property Line ,r+ <br /> DISPOSAL PONDS ❑ <br /> 4 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordin.Flces, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. { ` "fit <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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."ContractaPs 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 call for all requuiire,d�itispec' Complete drawing on reverse side. <br /> Signed X —- �' r Title: Date: <br /> T USE ONLY <br /> Application Accepted by A Date `~� Area�L r <br /> Pit or Grout Inspection by _ Date Final spection by Date <br /> Additional Comments: � "t �� <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tr y 835-6385 . "tl7.* . <br /> Applicant- Return all copie to:�Envir mental ealt ermit/S rvic 1601 E. Wazeltan ve O�Box tk., A 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a CASH <br /> E13-24(REV.itK5Y f�i <br /> 010 <br /> EH 14-28 — ] <br /> M [OMAI <br /> e7 <br />