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,yn APPLICATION FOR PERMIT <br /> 1" 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA , <br /> Telephone (209) 466-6781 h <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 /> Application Y <br /> made in compliance with San Joaquin County Ordinance Na.549 for sewage or No. 1862 for well!pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> / PM <br /> CZvd �Pff��D9 4�Jy City ST� Lot Size <br /> Job Address _ <br /> Address Phone <br /> Owner's Name <br /> !ri/CS'DJt+' Cf- License No. z�417 Phone_'�6��d <br /> tiSDpys Address 9* i <br /> Contractor DESTRUCTION C1TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 <br /> PUMP INSTALLATION 171 DISPOSAL <br /> REPAIR❑ OTHER ❑ <br />' SEWER LINES�' blSP05AL FLD. PROP, LINE <br /> DISTANCE TO !NEAREST: SEPTIC TANK <br />� FOUND <br /> ATI ONS <br /> AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE - TYPE OF BLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ElDomestic/Private ❑ Gravel Pack Ll Tracy Type sing Type of Grout <br /> Irl Public f f Other ❑ Delta Depth of Grout <br /> __Approx."Depth l 1 Eastern Surface Seal Installed by <br /> I Irrigation — State Wor e — <br /> Repair Work Done 13 Type of Pump H•P•Well Destruction ❑ Weil Diameter Sealing Material (top 50'1 <br /> l `Filler Material (Below 501 <br /> Depth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION DESTRUCTION i l aNailabpefwihin 200 fe permitted if public sewer is <br /> ' t <br /> Installation will serve: Residence v/Commercial— Other <br /> y Number of living units: Number of bedrooms3� Q <br /> :--- Water table depth <br /> Character of soil to a depth-of 3 feet1: _ No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity <br /> ' A Method of Disposal <br /> PKG. TREATMENT PLT. ❑ r i t <br /> Distance to nearest: <br /> Well �^"-'- ""Pad!tion a Property Line <br /> 1 *R i,1 <br /> +_ '�. <br /> LEACHING LINE ElNo. & Length of lines , Total length/size <br /> FILTER BED ❑ Distancetonearest: Well i Foundation s Property Line <br /> I . r`•_ <br /> I (ZSSizeNumber a f 4 <br /> SEEPAGE PITS <br /> Depth 00�� Foundation ! 0� Pro�pe�rty Lined 4 <br /> SUMPS Ll Distance to nearest: Wel1.�—. t j \ .0 <br /> DISPOSAL PONDS ❑ 'I $- m. <br /> I hereby certify that I have prepared tFiis application and that the work-will be_done in accordance wiitWSan Joaquinilcounty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. - <br /> "I certify that in of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as to become subject to workman's compensati6n�laws-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 must c r all regw d i[1s ns. Complete drawing on reverse side. L—��QO <br /> rt'507�'f�T� <br /> l <br /> Signed X Title: Date: <br /> ff <br /> f <br /> ... OR-DEPARTMENT USE ONLY <br /> I — Date q-0 Area <br /> Application Accepted by <br /> eF.irial Inspection by - Date a t <br /> 6or Grout Inspection by Dat ti <br /> .� <br /> Additional Comments: � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �. FEE AMOUNT DUE AMOUNT REMITTED RECEIVEO BY DATE PERMIT'NO. <br /> INFO <br /> EH 1 <br /> 3-14 IREV.t/H 51 <br /> EH 14-2e Or tl� <br />