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APPLICATION FOR,PERMIT <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (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. <br /> Job Address .3' � ✓!�'D72� hi®e„_ City Jai V Lot Size .20 A-CRr-A. PM <br /> Owner's Name Address Phone <br /> Contractor's Name;, /�/���ustf7`�9�; eIVS License No. �"S``/ ' ��I3' �� Phone 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ' DESTRUCTION, <br /> INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER Y❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -`_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS • <br /> ;❑ Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation ~ Dia of Well Casing <br /> 4-y'Y . <br /> F El Domestic/Private 171 Gravel Pack ED Tracy Type of Casing _ Specifications <br /> r .❑ Public ❑ Other ❑ Delta Depth of Grout Seal s Type.of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done t I Ik <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 Q <br /> Depth Filler Material IBelo 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ANo septic system permitted if public sewer is <br /> available within 200,'feet.l 'C <br /> Installation will serve: ,Residence Commercial_. Other <br /> Number of living units:—/— Number of bedrooms - 79 <br /> [ i r <br /> Character of soil to a depth of 3 feet: _ —Water table'depth <br /> SEPTIC TANK El. Type/Mfg 1 f f Capacity No.'Compartmehts •T <br /> PKG. TREATMENT PLT. ❑ y } 1 Method of bisp so al <br /> Distance to nearest: Well r Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of-lines }2- �^' � Total length/size 7 2 " <br /> FILTER BED ❑ I Distance to nearest:j- --wets,-�'fl'-/ Foundation�f Property-L'ine"-'� <br /> 'SEEPAGE PITS Depth Size__ __ l Number <br /> SUMPS ❑ Distance to nearest:' Well_ Foundation- 412 J Property Line r <br /> DISPOSAL PONDS ❑ II ' <br /> f Aga > .,•.t.S. r <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 agen- 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 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." t: <br /> �t <br /> The applican st call for all re 'e ins ctions. omplate drawing on reverse side <br /> Signed Title: __ Date: ' <br /> FaB DEPARTMENT USE ONLY <br /> Application Accepted by �3�� s '�Ik­ Date Area <br /> Pit or Grout Inspection by Date r/-°`-E3Y' Final Inspection by t' �" <br /> I <br /> Additional Comments: _ <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMII7ED' .^CK RECEIVED BY ' DATE PERMiT`NO, <br /> INFO CASH ti <br /> + EH 13-24(REV.10183) <br /> EH S <br /> 1426 7 O Q <br />