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APPLICATION FOR PERMIT f' <br /> SAN JOAQUIN LOCAL HEALTH!DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CEA. <br /> Telephone (209) 466-6781 4 <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> x (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 Counry 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 /> 5 , <br /> ''Job Address 9f1'- Z:? A �rh7­41n /-?c/ 1 City M4NT"-CJ4Got Size -7 PM <br /> { Pe 1"e•Y' R0 7' Address s.a1;'?i'/�'Cey. L.9 7'17 7v, get Phone �� `✓Y- r/ay!✓ <br /> +owner's NameJr <br /> (Contractor h', 41v hal✓ $$dN Address bOo� (�G.u,c�; yf4 /}JN- License No. yY� Phone <br /> ,TYPE OF WELL/PUMP:. NEW.WFLL 0 WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE <br /> 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 Pack ❑ Tracy Type of using' Specifications <br /> ❑ Public CI Other F1 Delte i: Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑. Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ` <br /> y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION l 1 DESTRUCTION l I Wo septic system permitted if public sewer is <br /> available within 200 feet.) k <br /> Installation will serve: Residence Commercial_ -Other 1`4v�' 14 o1w <br /> Number of living units: -- Number of bedrooms <br /> Character of soil to a depth of 3 feet: 5AAiel Water table depth 3DB f(>t k <br /> SEPTIC TANK Type/Mfg 1 &49!'e C 64 5 TCapacity d No. Compartments ;L <br /> PKG. TREATMENT PLT. ❑ 4 , .0 /0• Method of Disposal <br /> Distance to nearest:' Well Foundation �"� Property Line Or��oo� <br /> 4 <br /> LEACHING LINE ) No.'& Length of�lin`es 3 e�G z Total length/size y0 <br /> FILTER BED ❑ Distance to nearest: Well 1 d �: Foundation l,d ' Property Line <br /> U <br /> SEEPAGE PITS f I Depth Size Number U <br /> r <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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. <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 shall not I <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." , 1 <br /> The applicant must call for all required inspections. Complete drawing on reverse side. t <br /> Signed X Title:' Date: <br /> F DEPARTMENT USE ONLY 2 <br /> Application Accepted by Data J Area <br /> Pit or Grout Inspection by Date/"` Final Final Inspection by Dat /� <br /> Additional Comments: 147 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104., ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> + EH <br /> 13-24(REV.tiK5Y �� V` Sl —imD <br /> FH 144-T6 y 1 <br /> 1.� <br />