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SSS <br /> APPLICATION FOR PERMIT <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT A lkl <br /> 1601 E. HAZELTON AVE., STOCKTON, CA I <br /> Telephohe (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. pp <br /> /�,yam �J' O �/ <br /> Job Address _ +.� 1'►r�y�i / _ "-'� ity A*A) Lot Size 14 1M PM <br /> Owner's Name , N"►Y/7,r-� Yi✓�-J� � ddress r Phone -477-7431 <br /> Contrastor — �/ _ der ss i c e n s e No. �A Phone <br /> TYPE OF WELL/PUMP: NEW'WELLO WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMI5701`AL- :_ TIO SYS7 PAIR' O f lEfi"L'7"" -- <br /> DIS1•ANCE TO NEA!<iEST: SEPTIC TANK /JoSEWER LINES DISPOSAL FLD.` PROP. LINE , <br /> ----� � FOUNDATION _ AGRICULTURE,WELL '^"OTHER WELL------= PITS/SUMS <br /> INTENDED USI;' T Et61F WEtC'-�• PRQB,LEMAREA— CKNS_[flUCT10N SPECIFICATIONS 1r <br /> a +Er <br /> [IIndustrial ❑•Open•8ottom—'0 Manteca,- D"ia-4ofi-:Well Excavatio—n­_ Dia. of Well Jasing <br /> Domtestic/Private WGravel Pack ❑.Tracy r Type of Casing Specifications <br /> ("1 Public ❑ Other FI:Delta -Depth of Grout Seal Type of Grout <br /> 4 I <br /> I I Irrigation I _.Approx. Depth I I`Eastern v� Suui ce Sell Installed by _ <br /> Repair Work'pone'.� ❑ j Type 04,i, a` � P-P"" Z I State Work Done _ <br /> Well Destruction \❑ I Well Dialrite-fer ( i Sea ing 6.terial (top 50') i <br /> ) r <br /> E Depth �` Filfesf�llaterial (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I RtPAIR/ DDITION I I DESTRUCTION I I (No septic system permitted i public sewer is <br /> 1 {i\ �` available within 200 feet.) <br /> Installation will serve;�8esidence._,�.Commercial O.her .1 <br /> Number of living units: ti-- Number of bedrooms ✓ �✓ ' <br /> Charaber of soil to h depth'of 3 feet: Water table depth <br /> SEPTIC TANK r,,4 ❑ TyAe/Mfg •` r.) i Capacity No. Compartments <br /> �PKG-TRE6TMENT/PI<T.\Q!J 1 ! Method of Disposal <br /> ✓• `� Distance to nearest: ell Foundation Property Line <br /> LEACHING LINE ❑ No. & Lengt}t of lines Total length/size I <br /> FILTER BEd ❑ Distance to nearest-,,,' ..Well Foundation Property Line i <br /> SEI�AGE PITS I 1 Depth Size Number <br /> SUMS L1 Distance to nearest: WellFoundation~Property Line <br /> DISPOSAL PONDS ❑ �""—� <br /> 4 <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, an <br /> rules and regulations of the San Joaquin Local Health Di3trict. <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 subicontracting signatures <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 applicantrequir ons. Complete drawing on rev r side. <br /> I <br /> Signed X I Title: Date: <br /> 1 <br /> _� --- �F010DEPAF MENT-USE-ONLY� �--.— ^ <br /> Application,Accepted by ,, `` Date ��[ �Area <br /> Pit or Grout Inspection by Date "/o�-W.— Final Inspection by// r Date <br /> Additional Comments: v <br /> ❑ Stk 466-6781 D Lodi 1 ❑ Manteca 823-V104 ❑ racy 835-6365 ts <br /> Applicant- Return all copies to: Environmental Health Permit/Servjces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT' 0. <br /> +.EH13.241NEV.iIH61 S:7 <br /> EH 14-26 ! SYS <br />