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i 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 /> J (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 /> I 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 /> l <br /> Job Address <br /> ®� PM <br /> City /�'G Lot Size <br /> Owner's Name ' �� S77z:Z7 <br /> n�dress F 4 <br /> Phone <br /> Contractor S ddress ��,/ <br /> TYPE OF WELL/PUMP: License No, hone _ <br /> NE WELL WELL REPLACEMENT ❑ DESTRUC <br /> f PUMP INSTALLATION TION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES <br /> DISPOSAL FLD, f:7 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL-r— <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USES TYPE OF WELL PROHLEIvIAREA Industrial CONSTRUCTION SPEClFICATIO�fS <br /> DL7 _ ❑ Open Bottom ❑ Man~teca ~— Dia. of Well Excavation E— <br /> omestic/Private ravel Pack ❑ Trac Dia- of Well Casing <br /> " f'1 Puhl c... Y Type of Casing � j <br /> f_� Delta a Specifications .. <br /> ♦ n Other Depth of Grout Seal Type of Grout <br /> I I Irrigation"° Approx. Depth I I Eastern <br /> Repair Work Done ❑ T �Cl��s urfa a Seal Installed byType of Pump -� H P 4 �_ State Work Done <br /> Well Destruction ❑ Wel! Diameter <br /> - Sealing Material (top 5011 <br /> ' Depth" Filler Materia! (Below 5o') J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I-fNo septic system <br /> E permitti <br /> �. t r ed i( public sewer is !1 <br /> Installation will serve: Residence Commercial available within 200 feet-1 <br /> Other-�� � - <br /> Number of living units: Number of bedrooms• <br /> Character of-soil to a depth of 3 feet: <br /> SEPTIC..TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. CICapacity No. Compartments r <br /> "g Distance to nearest: WellK MethodofDisposal <br /> Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines %# <br /> FILTER BED ❑ Distance-to nearest: Well Total length/size <br /> Foundation Property Line e- <br /> SEEPAGE PITS I 1 Depth <br /> Size Nurnber <br /> SUMPS 0Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line <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 /> •� Home owner or licensed agent's signature certifies the following: <br /> employ an g: "'I certify that in the performance of the work for which this permit is issued, I shall not <br /> P Y y 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." w"Y`'" p <br /> The appli <br /> Signed X /cant 4 I equir ,ns Complete drawing on re side. <br /> r , <br /> Title: C <br /> ~� Date: O <br /> DEPARTMENT USE LY <br /> Application Accepted y <br /> Pit or ro I nspecti6n b ' ate Final -- kk <br /> DIns y Date I <br /> /• pection Date Area <br /> b <br /> Additional Comments: � ; <br /> ❑ Stk 466-6761 '❑`'Lodi 369-3621 ❑ Manteca 823-7104 <br /> Applicant 5-6385 <br /> - Return ally pias to: Environmental Health Permit/Services 1601 E.❑Hazelton Tracy 83 Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE " AMOUNT DUE CK <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMIT'NO- <br />+.fH 13-24 tREV,riKS, �� �V �� <br /> EH a-Ze C7 10 O o—� <br /> � 6 l3 Pv p- , <br />