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is <br /> APPLICATION FOR PERMIT <br /> 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. �t /� <br /> s[7/' City�� Lot Size PM <br /> Job Addressf n �+t► <br /> Am <br /> ddress .97 3 4A) <br /> J"" Phone <br /> Owner's Name. a ] / <br /> Contractor LV _Address G r � r License No.3�•'6 O Phone <br /> TYPE OF WELL/PUMP:. _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION F-1r <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS n <br /> ❑ Industrial ElOpen Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r Specifications <br /> ► 0 Domestic/Private ❑ Gravel Pack ❑ Tracy,' Type of Casing P — <br /> 71 f1 Other Cl Qe1ta'. Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Dept fr eastern Su ace Seal Installed by <br /> D <br /> Repair Work Done ❑ Type of Pump H.P. State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> f rQepth i Filler Material I8elow 501 <br /> TYPE OF SEPTIC WORK:` NEW iNSTACLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:' Residence= Commercial Other <br /> Number of living units: Number of bedrooms IR <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK " ' '❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ T o `� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> FI <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L) Distance to nearest: Well Foundation 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 tha_performance of the.work for which this permit is issued, I shall not <br /> employ any person in such manner as it i become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following:';I certify that' the_ aUns. <br /> a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alif rnia." <br /> k <br /> The appiica m t c I or allll r q red ns ctio�ple awing on rev sido. r <br /> , "V 4itle: lfll Date: a r <br /> - Signed X � <br /> FOR-13EPARTMENT USE.ONLY 1— <br /> Application Acceptedrbyl ; ° / t Date' <br /> _Pit.or..Grout-Inspection.by <br /> r5"_'Dater a _Final Inspection by Date 10� ? <br /> t � <br /> i <br /> Acjdiiional Comments: <br /> Tlicant <br /> tk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 n Trac 835-6385' <br /> - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P-O. Box 2008, Stk;CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ' <br /> INFO <br /> �14 fREV.I/H b7 <br /> 7 l� <br />