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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Nt`� V.1Z40/la-'r <br /> 1 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 # <br /> n r4 `�s A <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUEDI��.� U ` <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 /> unty Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules and Regulaiions of the San Joaquin <br /> made in compliance with.San Joaquin Co <br /> 3 Yrr I <br /> Local Health District. <br /> a t C f r �'}(` /�i�, City Lot Size B D M <br /> Job Address <br /> i <br /> 0 0J t � <br /> Address Phone <br /> Owner's Name a r <br /> �__ �— _--€• - -^�-�— --._.. —. -- �. ^y <br /> Phone' <br /> Contrac cess License No, <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ F <br /> PUMP INSTALLATION SYSTEM REPAIR I-) OTH <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> EWER LINES DISPOSAL FL PROP. LINE <br />` FOUNDATION A CULTURE WELL OTHE LL PITS/SU <br /> 11APS <br /> 3 5' I <br /> INTENDED USE TYPE OF WELL -PRO BL'EM ARE -—CONSTRUCTIO CIFICATIONS <br /> E] Eln Dia. of Well Casing <br /> k Industrial Open Bottom ❑ Manteca . o Excavatio <br /> I f Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of.Grout <br /> Fl Public ❑ Other a Depth o out Seal YP <br /> ❑ Irrigation epth ❑ Eastern Surface Seal ailed by r <br /> r H P State Work Done <br /> Repair Work Don El Type of Pump <br /> Well Destruction Ll Well Diameter Sealing Material /top 50'1 e <br /> Depth Filler material.(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION a DESTRUCTS aNailjo septic thinsystem200 feetpermi.) public sewer is <br /> f Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms :- <br /> r <br /> Character of soil to a d pth of 3 feet: I-WAter table depth <br /> 1 <br /> T e/Mf Capacity No. Corttpaitments <br /> SEPTIC TANK yl? g ' i ! <br /> r Method of..Disposal <br /> PKG. TREATMENT PLT. ❑ fi. , :,s,s <br /> Distance to nearest: Well Foundation Property Laine <br /> i 9 <br /> - Total length/size ' T r <br /> LEACHING LINE ❑ No. & Length of line's--, �. ,�-- <br /> FILTER BED 1-1Distanceto nearest: Well Foundation Property Line <br /> li <br /> SEEPAGE PITS ❑ Depth Size Number 4 <br /> ` Foundation Property Line <br /> SUMPS 13 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ t <br /> will be done in accordance with San Joaquin county ordinance s..state laws, and <br /> I hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin Local Health District.. <br /> Home owner or licensed agent's signature certifies the following: "1 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." 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 Snrorkman's compensa- <br /> tion laws of California." <br /> app is ust call for all required inspections. Complete drawing on reverse side. <br /> f <br /> Signed X Title: >v,]Y1AI� Date: <br /> R DEPARTMENT USE ONLY <br /> ( Date Area <br /> Application Accepted by # <br /> { # Date Final inspection by Date <br /> Pit or Grout Inspecti n b <br /> Additional Comment <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 <br /> h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to; Environmental Heat <br /> f <br /> CK t RECEIVED 8Y DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED GASH+ EH 13-24(REV:i/a 5 - ' <br /> + EH 14-28 _ <br /> 1 �r <br />