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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA , <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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 of the San Joaquin <br /> Local Health District. <br /> 1� � City Lot Size PM <br /> Job Address t <br /> d^ sne <br /> Owner's Name <br /> S * T Contfactor Address '�sicense N­o_�_// Phone <br /> TYPE OF WELL/PUMP:, NEW WELL ❑ ' , l WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-R-EPAIR-❑— OTHER Cl <br /> DISTANCE TO NEAREST:.SEPTIC TANK t 1 SEWER LINES DISPOSAL FLD. PROP�INE ; <br /> FOUND`AT10N w. ? ,AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE -'.E,& WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial "f❑,Open-Bottom> ❑ Manteca Dia. of Well Excavation <br /> Dia, of Well Casing }. . <br /> ❑.Domestic/Private ❑ Gravel Pack..j # ❑ Tracy �' Type of Casing « ; Specifics[ions <br /> I Type of Grout Fr <br /> r" <br /> fl Public [ ] Other �F x Cl Delta; I Depth of Grout Seal _ <br /> }� " �.-Apprax. Depth E I Eastern I Surface-Seal-lnstalted-by-� - - <br /> i I Irrigation = <br /> t H. State Work Done_ /= <br /> Repair Work Doe CJ Type-df"Pump i <br /> Well Destruction ❑ WeIIADiameter i f -`"" —Sealing-Material-Itop 501 <br /> .'t j °s r rFille�Material iBelow 50'1 <br /> Depth , _ _ <br /> TYPE OF SEPTIC WORK: NEW INS'TALLA1110N I.1 REPiAIRtADDITION ESTRU TION 11'ANo septic system permitted if publicseweris <br /> available within 200 feet.l�, , <br /> Installation will serve: Residence,' Commercial llel�'13ther � ----- fr <br /> Number of living units: � "" " Numberlo� rooms <br /> Character of soil to a depth of-3 feet.' �3 rl ' -- - ' Water table depth ' <br /> SEPTIC TANK E ❑ Type/Mfg" `ti i - Capacity ,., �No. Compartments <br /> PKG. TREATMENT PLT. ❑ m �� --T- - --- Method of Disposal" ' F <br /> DistartctY to nearest"'�"Iltilell Foundation Property.Line <br /> ` 1 -X Total length/ <br /> LEACHING LINE ❑ No. & Lehgthc.o`ftliries" g ,r <br /> FILTH Dis ance. o nearest'. 1/Ue11 Foundation _-Y Property Line j t' <br /> SEEPAGE PITS [ I Qepth !` Size _ Number <br /> # e <br /> 1 Distari fe"to nearest: Well 9FoundatibYi -"� `Property Line l �f <br /> SUMPS L <br /> l <br /> DISPOSAL PONDS ❑ <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, and <br /> rules and regulations of-the-San Joaquin-Local Health•Di?;trict. <br /> 1 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 io 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 compensa- <br /> tion laws of California." <br /> The applicdnt rAusi call INr all requiredi • pections. mplete drawing onireverse-side:'"'-'""--j <br /> Signed X r <br /> Title- + a Data: <br /> _ �� k <br /> FQ EPARTMENT E ONLY .. <br /> Date /Area <br /> Application Accepted-by - r y <br /> i + .A.__- _. .-__ Dat t "Elba/ Inspectioil`by Date <br /> Pit or GroUt'lhspedtioh liy' -�- a <br /> Additional Comments: <br /> i, ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca, 623-7104 -- L7 Tracy 836-M----, # <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave�P.01 Box 2009, Stk., CA 95301 <br /> FEE AMOHTO2 EAMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. LG\ <br /> ' INFO <br /> +.-EH 13-241REV 1/H51_ _� Z. '_� -'"" _ :7'-A 4 <br />