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w <br /> Y <br /> 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 /> (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. <br /> Job Address(�3(!)-] <br /> /� �- �C� . °'� - City Lot Size actcAj PM <br /> Owner's Name/Y-�41 - Address 0 A),Y, Phone ' <br /> Contractor's Nan License No. Phone ff-'s/65\ <br /> TYPE OF WELL/PUMP: NEW WELL ❑' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FI_D. 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`, ❑..T.rpcy Type of Casing Specifications p ] <br /> ❑ Public ❑ Other 1d Delta Depth of Grout Seal Type of Grout N <br /> ❑ Irrigation --Approx. Depth ;O"Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum 'f '�/"� <br /> p yp p � •., { H . State Work Done <br /> Well Destruction ❑ Well Diameter ' Sealing Material (top 501 <br /> Depth Filler Material�(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ I DESTRUCTION ❑ (No septic system permitted'if public sewer is <br /> � available within 200 feet.) <br /> Installation will serve: Residence A Commerzcial Other )Zb#rY/�(�Jr-71L( <br /> Number of living units:— ,Number f edro"Ams / <br /> Character of soil to a depth of'3 feet: Water table depth _0+ <br /> SEPTIC TANKType/Mfg 1 .. , y Capacity 6 No. Compartments <br /> PKG. TREATMENT PLT..❑ 'R 7 Method of Disposal " <br /> `(p Distance to-nearest: Well IQ'Foundation /e Property Line 7- <br /> LEACHING LINE' 21 No& Length=of-lines-4�- Total length/size X s /] <br /> FILTER BED/ :Uistanc'e o nearest: Well i4�2 Foundation_�Yf Property Line��� V ' <br /> SEEPAGE PITSS Depth �S Sizes _ Number <br /> SUMPS( ❑ Distance to nearest: Well .W01 Foundation_ Z 4 Property Line <br /> ,DISPOSAL7rPONDS--"!-0` 1 <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 ofthe San Joaquin Local Health District. <br /> Ij Home owner or Icensed•'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-Califor-nia. ---�-�, <br /> The 4applicant rhust call o4, 11 required inspections. Complete drawing on reverse side. <br /> Signed l C Title: — •�. Date: 4G C. <br /> �!/��-.1�-77� -DEPARTMENT USE.ONLX �-- -- - 7-- - <br /> Application Accepted by ,.'_1 _ Date Area 2 <br /> Irout Inspection by Date � Final Inspection by Date <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant RetOrn all copies-to: Environmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2D09,--Stk.,-CA 96201 <br /> a <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•'NO.' <br /> rr,,1426 <br /> 3-24(REV.10r83) <br /> EH x'15. "e, I�LVR-4 <br />