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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 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. 1B62 for�welllpump and the Rules and R�ulations of the San Joaquin <br /> Local Health District. <br /> AVr7�1� vV City Lot Size PM Ste.•= <br /> Job Address <br /> A- ::i:3, Phone <br /> Y Address <br /> Owner's Name fi _ <br /> License Na. <br /> 'rAddress-- � r1t l <br /> Contractor`'- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OFIWELL/ UMP: NEW WELL ❑ OTHER C1PUMP INSTALLATION IJSYSTEM REPAIR Ll <br /> SEWER LINES --- DISPOSAL FLD. PROP. LINE <br /> F DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> INTENDED USE �—�— <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 <br /> ❑ Industrial Specifications 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> [l public i 1 Other F [-1 Delta 3 _ <br /> �_Approx. Depth [ I Eastern Surface Seal Installed by <br /> I I lrrigation j' State Work Done <br /> H.P. t <br /> Repair;Work Done ❑ Type of Pump ---- Sealing Male%1 [top 501 <br /> Well Destruction ❑ Well Diameter <br /> Depth } Filler Materlr(Below 501 .y� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITkON�I f fDTSTRUCfTIQN�.i (No <br /> ailabpel�Jit in 200 feeftMo- i ublic sewer is t� <br /> I 1 J 1 <br /> installation will serve: Residence 3 Commercial– Other <br /> Number of living units: Number of be loo ms Water table depth"' <br /> Character of soil to a depth of 3 feet: _ £ +f d00 No. Compartments <br /> Type Capacity <br /> SEPTIC TANK ❑ r Method of Disposal { `� <br /> ii <br /> PKG. TREATMENT PLT. ❑ <br /> ' Property-Line <br /> Distance to nearest: Well Foundat'°°�--�•--- <br /> t ;�� Total length/size <br /> LEACHING LINE ❑ No. & Length tof lines Property Line <br /> ct <br /> ❑ Distance o nearest: Well�— Foundation 1 <br /> FILTER BED I ��,1� 1 <br /> Size ��' t: Number <br /> SEEPAGE'PITS 11 I'< ` /�oundatia# _ Property Line 5--^-7 <br /> SUMPS / Distan'a two nearest: Well <br /> DISPOSAL PONDS <br /> I hereby certify that 1 have prepared this application,and that the�work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> l not <br /> rules and regulations of>the San Joaquin Local HealtfDtrict./r i1 <br /> s issued, <br /> rmance of <br /> work <br /> Home <br /> owner or licensed agent's signature certifies the followii g: "I certify tfiat i�heIperfoof California�g Contraot rs'hvingr oPsubt�ont actinglsgn[ature <br /> employ any person in such manner as to become subject to workman's compensate n laws rsons subject to workman's compensa- <br /> I certifies the following: "I certify that in the performance of ttra work for which this permitis issued, I shall employ pe t <br /> (tion laws of California." // t ..� <br /> I The ap icaM mus cal or all r wired Inspections.,Complete drawing on rel' a side. iv <br /> Date. <br /> } ' Title: <br /> I Signe "- <br /> ff � � l <br /> C � F DEPARTMENT USE ONLY <br /> J r' Date Area <br /> Application Accepted by - I <br /> f # Final lnspe`ction by !Date <br /> Pit or Grout-lnspecti&h—bye Date�� <br /> k `- Ad td Tonal Comments: 11` <br /> °�❑ Stk 466-6781 ❑ Lodi 369'4621 ❑ Manteca a23-7104 © Tracy 835-6385 <br /> . B,,2 <br /> Applicant - Return all copies to. Eriirvironmentai Health Permit/Services 1601 lton Ave P.O. Box 2009, Stk., CA 85201 <br /> 1 , <br /> AMOUNT DUE AM(1t9r3T REMITTED CASH tf <br /> ,RECEIVED BY DATE PERMIT NO. <br /> FEE C� I <br /> INFO "� Ja <br /> ..EH M'24(REV.1/K5) n O, �y <br /> EH 14-2e <br />