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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Completein Triplicate) <br /> is <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 aPPI+fin <br /> . made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for wall/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. rr. 'f` <br /> 6- ,C. Z14 p i! City��� Lot Size A _Y PM <br /> Job Address e— <br /> � ryry n�` � ewe�� Address �iat *vz Phone <br /> Owner's Name —*A,&) 4� <br /> ° License No. _S Phone "! <br /> Contractor L. iiw Address a, P <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 4 DESTRUCTION ❑ 4t, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE <br /> TO NEAREST: SEPTIC TANK SEWER LINES.. DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATION AGRICULTURE WELL OTHER NVELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> INTENDED USE Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom._.__—❑-Manteca..__-- Dia._of_WeILExcavation ) <br /> T of Casing-01Specifications 1 <br /> ❑ Domestic/Private ❑ Gravel!Pack ❑ Tracy y� Type of Grout i <br /> El Public ❑ Other} ❑ Delta Depth of Grout Seal <br /> ---Approx. Depth ❑ Eastern Surface Seal lnstalled;by <br /> ❑ Irrigation _appy. \ ? 1 <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter 1. Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EJREPAIR/ m perm <br /> ADDITION� DESTRUCTION ❑-avail bletwthm 200 feetitted if public sewer is <br /> G Installation will serye: Residence Commercial Other t <br /> Number of living units: 1 — Number of bedrooms �;J Water Table depth <br /> Character of soil to a depth of 3 feet: C'n� i <br /> Capacity :No,Compartments �. <br /> SEPTIC TANK ElType/Mfg r'•"`" '' ''Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well .} FouNatioh's yY`..P�roperty Line 1 <br /> ,r1. / � .. <br /> LEACHING LINE Ci No. & Length of lines !1 Totaiilength/size i <br /> Distance to nearest: <br /> Well <br /> yfouildation a i Property Line <br /> FILTER BED u <br /> k <br /> r,I.i. v <br /> SEEPAGE PITS ❑ Depth Size- Number <br /> ,1, ? Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation— I <br /> DISPOSAL PONDS ❑ I' <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. i+ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the womk 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 CaGfornia.:'_ConUactors hiring or sub contracting signature <br /> certifies the fol owing:"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 or Cailit M18. <br /> The appli nt mut all fo squired inspections. Complete drawing on <br /> 'reverse side. <br /> r._. - - Title Date: I 0 <br /> - Signed 1 _ W <br /> FOR DEPARTMENT'USE ONLY <br /> io� <br /> p.0 Date ? Area <br /> Application Accepted byLy—p4 <br /> .; vPit or Grout inspection byDate Final Inspection by` f f Cam--� Date <br /> 'I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy .. - <br /> Applicant- Return all copies-to:'Environmental'Health Peraf1_Seivices 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> CK <br /> FEE RECEIVED BY DATE PERMIYNO. <br /> INFO -AMOUNT DUE AMOUNT REMITTED CASH <br /> 3z� <br /> + EH 13-244REV.1/851 �' Q <br /> EH 14-28 <br />