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APPLICATION FOR PERMIT <br /> �J 6 <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 f�_l �S �~ 1��� !_la� u. City r Lot Size PM <br /> Owner's Name 1A�� I�f a Aw C +.e—L&kl Address �/� 7 4e ea -;r'e.. S Phone 3' <br /> Contractor's Name V License No. 7 �, Phone �� y <br /> TYPE OF WELL/PUMP: NEW WEiIMW WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLPROP. LINT <br /> - FOUNDATI AGRICULTURE WELL/ OTHER WELL PITS/SUMP <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Weil Casing <br /> 9 Domestic/Private ❑ Gravel Pack _❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout; <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') N <br /> Depth Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑,(No-septic.system_permitted if..-public sewer-is-- <br /> .� . - "4"- �+� ---�` +— +- - - - available within 200 feet.) <br /> Installation will serve: Residence--Y- Commercial_ Other <br /> Number of living units:/ Number of bedrooms <br /> Character of soil to a depth of 3 feet: .5r4 A g el+. �. Water table depth <br /> SEPTIC TANK Type/Mfg ��Aie 1 CapacityL-Z.&D No. Compartments <br /> PKG, TREATMENT PLT. ❑ ` 4. Method of Disposal ' <br /> Distance to nearest: Well 1 �+f Foundation � Property Line <br /> i •r• i� <br /> LEACHING LINE ® No. & Length of lines Total len th/size ZO <br /> 9 g <br /> FILTER BED P Distance to nearest. Well 154D Foundation Property Line -2 S <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 J <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 Zired inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPA ENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental a Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " <br /> I INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> + EH 1324(REV.10/83) -767 � a Q p } 3/ gb " 7 <br /> EH 14-26 <br />