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L <br /> APPLICATION FOR PERMIT <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 7riplicate) '• x r �., r� r <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 /> t Local Health District. <br /> a Job Address TL&D r r City ti` t Sized VEL PM <br /> Owner's Name - � -"_--� - <br />' __ Address -. Phone <br /> r _ �✓ k <br /> Contractor's Name �E— 1r -X <br /> A Li�'�� - License No. �b] [ 4 _1Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP-INSTALL-ATION-B---w-- ^ -•=SYSTEM-REPAIR--E-- OTHER-2— <br /> DISTANCE <br /> THER- ]DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Il_lndustr"ial ��O-Open_Bottom ❑.MantecDia..of Well_Excavation_ .- -.. --- -Dia...of,.Well Casing_ <br /> ❑ Domestic/Private El.Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ❑ Public t ❑etherDelta Depth of Grout Seal Type of Grout <br /> ❑ IrrigationsiRpro CJ-Eastern If Surface Seal Installed by f <br /> Repair Work Done.,❑ Type of Pump t H.P. f r State Work Done <br /> Well Destruction' 41❑ Wali Diameter �� i Sealing Material {top 50') <br /> Depth - Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATJON L1rREPAiR/ADDITION:' DESTRUCTION ❑ (No septic system permitted if public sewer is <br />.t .I.- - Iavailable within 200 feet.) <br /> Installation will serve: Residence commercial Other <br /> Number of living units:�Lv Number of bedrooms ' _ <br /> Character of sail to a depth of 3 feet: �' # �"" "`°'* ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfgr Capacity No. Compartments ' t <br /> ` <.• l 1 --� <br /> PKG. TREATMENT PUT. ❑ Method.of pis osaf" <br /> I Distance-to nearest: Well IQQER oundati?3� Property Line 77 <br /> LEACHING LINE ❑; ',No. & Length of lines Total length/size <br /> FILTER BED C7 Distance,to nearest: iWell'Foun'aationroperty Line`� t <br /> SEEPAGE PITS Q—Papth Size l?Number l+ <br /> E <br /> SUMPS ❑ Distance to nearest: Well Foundation^ I # Property tine �^k <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 Sart Joaquin Local Health District. <br /> Home owner or licensed agent-'s signature certifies..the.following:.,:tl certify.that.in the.perforniance of the work for which this permit is issued, I shall not <br /> r5 employ any person in such r anner 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 comf ansa- <br /> tion laws of California." r P <br /> 756e-9ppli nt must call fog II Yired i �cfi s. plete drawing on r arse side. 'A <br /> Signe Title: ! - Date: <br /> �OR DEPA'FlT11A Nf USE ONLY <br /> Application Accepted by Date Area t <br /> Pit or Grout Inspection by ' Data " /J (Final Inspection by `�`� ,y[_ Date <br /> Additional Comments: _ �VC.C ' v Luft/ �l`c.�}� "�-, ' " "i`(� /t/`�✓C` v�'r1i/�L <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 CI Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health PermR/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEit <br /> INFO AMOl1NT DUE r� AMOUNT REMITTED ICSH RECEIVED BY DATE PERM `Nq. ' <br /> . ... <br /> y +Efik 13-24 fREV.10!931 141 <br /> EH 1429 it <br /> z <br />