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log <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> i�. (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 'A' UQ�''�f 1 CityLot Size PM <br /> qty t � y ; <br /> Owner's Nam,-� I�-i' ��h7 �-_ Address . t Phone <br /> Contfacioruop0=1A=h I I AddressLicense No. Phonea <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP` NSTALLATION-❑ SYSTEM"REPAIR-[J--`" ' 'OTHER"❑" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> - INTENDED USE TYPE OF!WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y <br /> 5.1- —9 <br /> ❑ Industnal �` ❑ Open Bottom ❑ Manteca Dia: o Well Excavation Dia:'of'VIletl`Casin <br /> ❑ Domestic/Private 1-1Gravel Pack ❑ Tracy t " Type of Casing Specifications <br /> ! f'l Public F Other r ❑ Delta Depth of Grout Seal ' Type of Grout- <br /> ..� . <br /> l�l Irrigation-_- _•*^-`-w__ApproK.tf]epth --1,l Eastern­t�Surface-Seal-Installed bye- �---,------ _ - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> r+ <br /> Well Destruction ❑ . Well Diameter Sealing Material atop 50'I q <br /> ...,Depth = Filler Material (Below-50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11',REPAIR/ADDITION ESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:.w Residence L--C..merciai Other, r r <br /> r Number of living units: 7(-- Number of bedrooms t f• <br /> "Charactef of sail to a depth'of'3 fe-et: y+1��) r "Water table depth 4" <br /> ° SEPTIC TANK ❑ Type/Mfg Capacity -.No. Compartments <br /> PKG. TREATMENT PLT. O r . Method of Disposal <br /> "-Distance to nearest:" Well Foundation " ' ':Property Lirie ' <br /> LEACHING LINE" No. Length of lines Total length/size i <br /> - " FILTER BED "` ❑" Distance to nearest. -, Well Foundation :f "Properly'Line " <br /> 7 <br /> SEEPAGE PITS t\L- Depth Size Number + <br /> SUMPS,' T' ❑' Distance to neatest: Well Foundation q Property Line <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 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 /> - �amploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature } <br /> { certifies the following: " rtify that in fheperformance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> ti n.a CaIifor a." <br /> i The applican fI for all r uir ins ions. p rawing o revers side. <br /> Sig itle: Date: <br /> k FQR TMENT USE ONLYApplication Accepted by r :�R <br /> bate Area w <br /> IL <br /> Pit or Grout Inspection by pate .Final Inspecnon.by R E�lav Date <br /> Jk- <br /> Additional Comments. e <br /> t - ❑ Stk 466-6781•-- -•-.❑ Lodi 369=3621 ❑ Manteca'623-7104 — O'Tracy ;a35-6385 ` <br /> Applicant - Return all copies-to: Environmental Health Permit/Services 1601 E. Hazelton Ave'-L P.O. 80x.2009, Stk., CA 95201 <br /> .. .._. <br /> --"-- I..FEE AMOUNT DUE AMOUNT REMITTED CK4 RECEIVED BY ipATE PERMIT NO. c <br /> INFO CASH <br /> +.EH1344{REV.1/H5l <br /> EH t4-?8 <br />