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N <br /> L f <br /> f 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 TYEAR 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. k <br /> f. <br /> Job Address -20 x A3 �• 40 �Pr Rie+f• City5CALOeV Lot Size PM <br /> r =" Owner's Name Address Phone <br /> E Contractor �!1° f shy Address ��R *('0 e I Ave, License No, yf✓�g9r Phone me•ux 1 <br /> I TYPE OF WELL/PUMP: _ NEW WELL ❑`;#*-� WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP,INSTALLATION ❑ _ - SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEAREST: SEPTIC WANK SEVVER'LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 4!AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial ❑ Open Bottoma ❑ Manteca Dia. of Well Excavation Dg of Well Casing <br /> L1 Domestic/Private ❑ Gravel Pack M'Tracy `ti Type of Casing » ' Specifications <br /> ! d 71 Public 1-f Other � !H'Deltai De th of Grout Seal Type of Grout <br /> _ p <br /> { I Irrigation _.Approx, Depth ''I I.Eastern°f Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') ♦ r f <br /> } Depth' Filler Material (Below 501 v k' <br /> f f TYPE OF SEPTIC-WORK;-NEW INSTALLATION 1 1 REPAIR/ADDITION k7r DESTRUCTION[ I F1No septic system permitted if public sewer is r N <br /> available within 200 feet.) <br /> 3 °Installation will serve: Residence J_ Commercial_ Other ,( • <br /> Number of living units: —J Number of bedrooms <br /> Character of soil to a depth of 3 feet: __$Awd La-i)M "•, Water table depth � - <br /> �.e k <br /> SEPTIC-TANK— 1ZP Type/Mfg s - CapaciNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Y. _Method-of Disposal <br /> '� <br /> Distance to nearest: Welt � Foundation ya Property Line <br /> f LEACHING LINE_ r Ir No. $ Length of lines 6�' I Total length%size j%t <br /> FILTERBED r ❑ Distance to nearest: Well Foundation Property Line <br /> y , SEEPAGE PITS 1 1 1 Depth Size I Number 'Z I <br /> { F SUMPS LA Distance to nearest: Well ��f7` Foundation `tea` 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 <br /> employ any person in such manner as to become subject to workman's compensation.-laws-of-California."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 call for all required inspections. Complete drawing on reverse side. <br /> li r <br /> Signed X_� _ Title: Date: 1't 9 8'} <br /> FDR DEPART T USE ONLY <br /> 4 <br /> ZZ . � ) 3 <br /> [. Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: ' <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 /> � y <br /> FEE <br /> INFO AMOUNT DUE.. .,- - AMOUNT REMITTED CK RECEIVED BYr.� DATE PERMIT"NO. <br /> a EH 1124 IREV.i <br /> EH 14-28 <br />