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APPLICATION FOR PERMIT SAN JOAQt IX, LOCA+. HrAl-TH DJSTRICT <br /> SAN JOAQUIN LOCAL HEALTH DIST iROI"�NI N-LAI `))VlSjON <br /> 1601 E. HAZELTON AVE., STOCKTON, CA SPECIAL. <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 Cit �nU <br /> Y �� Lot Size PM <br /> Owner's Name C4�4r� Address hone <br /> ',,/' I /� BST <br /> ConEractor evAt- 14 of �Ge Address_/L/g1C4364- CA �67/_?_? Phone 02,3 <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ( SYSTEM REPAIR LJ OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ i _ SEWER LINES 3� DISPOSAL FLD. PROP. LINE <br /> r <br /> # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f�industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C/ <br /> C0 Domestic/Private Pack ❑ Tracy Type of Casing r Specifications <br /> FI Public f-9tpeaM,D V tMl- ❑ Delta Depth of Grout Seal Type of Grout <br /> f I Irrigation -ApproJ Depth I i Eastern Surface-Seal Installed by c <br /> Repair Work Done ❑ Type-of Pum' 'Ary, t` <br /> p H.P.�Z Stats Work pone_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> i <br /> TYPE OF SEPTIC WORK; NEW.INSTALLATION 1.) REPAIR/ADDITION I 1 DESTRUCTION I 1 lNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence! Commercial Other 9 <br /> Number of living units: Number of bedrooms <br /> I <br /> Character of soil to a depth of 3 feet:I Water table depth i <br /> SEPTIC TANK O Type/Mfg( Capacity - No. Conpat"r <br /> PKG. TREATMENT PLT. ❑ Methodj$fIBilj <br /> Distance tb nearest: Well Foundation Property.Line <br /> _ 4 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size MY 8 1-989 <br /> FILTER BED ❑ -Distance to nearest: Well Foundation )1ProperI <br /> t l"RONMER TAL HEALTH <br /> SEEPAGE PITS i I Depth i SizeNumber SERVICES ,. <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 Dr"strict. <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 m call fo II ired inspections. Complete drawing o reverse ide. <br /> Signed X i <br /> f� <br /> Title: .0.-A 4 Date: <br /> FOR P MENT SFO Y <br /> �. <br /> Applica on ccepted by Date r� 1 Area �3 <br /> Pit or Grout Inspection by Date Final Inspection Icy Date <br /> fEC- Al wor, �lt��5i IgBB t Fx Z,/QBQ <br /> Additional Comments: <br /> ❑ Stir 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. Box2009, Stk., CA 95201 <br /> FEE $ <br /> AMOUNT DUE AMOUNT REMITTED CASH INFO }� CASH FiECEiVEp BY GATE PERMIT"NO. <br /> +.EH 13-24(REV.1/9 51 } �� <br /> EH 14-28 1Z I <br />