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APPLICATION FOR PERMIT Y <br /> i rimer: 4 <br /> O. <br /> SAN .lOAUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> i C, <br /> Job Address u ' 01 �i 18+6 S Gt' City `! Lot Size � PM <br /> Owner's NameI__._� £7n s l 1---l_ Address a3 4 57 Ct Phone (9:5'C <br /> Contractor_ LI ft i� Address T T 1 � I q�I _TLicense No. a'Phone J o'" C i <br /> T 1OF WELL/PUMP: NEW WELL ❑ WELL.REPLACFMENT ❑ DESTRUCTION ❑. "Vl <br /> r.-.._..l SYSTEM'REp,41R ❑' - _ .�._ v_._..OTHER Ll _.r..._ -� ----- <br /> ° PUMP"INSTALLATION-❑ <br /> DISTANCE TO SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE �} <br /> i <br /> !��FON ;AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR i CONSTRUCTION SPECIFICATIONS / f <br /> ❑ Industrial ; ❑ Open Bottom ❑ Manteca Dia. of e n ;; � .Dia. of Well Casing <br /> ,_ -�4,_ .��,s <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of`Casing Specifications I <br /> ❑ Public ❑ Other r] Delta Depth of Grout Seal Type o but <br /> ❑ Irrigation i ---Apprx. Depth Q Eastern r Surface Seal'-Installed by <br /> Repan Work Done ❑ Type of Pnp H.P. State Work Done <br /> i <br /> Well bestructiori ❑ Well Diameter . Sealing Material (top 501 + —� <br /> Depth_ ? <Filler Material (Belo ) <br /> TYPE:OF SEPTIC WORK: NEW INSTALLATION,D REPAER/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence—c,M: mercial <br /> Number of-living units: Number of edrooms s <br /> _._� <br /> Character of.soil to a depth of 3 feet: "° """" Water table depth <br /> SEPTIC TANK' ; ❑ Type/Mfg i )! Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> 1 <br /> ! s Distance to nearest: Well ! Foundation Property Line—' <br /> LEACHING LINE No. & Length of ines�'. "Tstal length/size <br /> FILTER BED El Distance to neareat:�' WeiE Foundation Property Liner <br /> i. SEEPAGE PITS, ❑ Depth Size Number <br /> SUMS 's ❑ Distance to nearest: Well A Foundation Property Line <br /> DISPOSAL PONDS ❑ 4'� �""� "'� '� <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 /> 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." <br /> S The applicant !must call for al requui�i``red inspections. Complete drawing on reverse side. <br /> Signed X__ ! � ?Y � Title: Date: <br /> ;/ <br /> .t< <br /> FOR EPARTM T USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 5-2,0 <br /> Additional Comments: <br /> ❑ Stk 4664781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 <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 REMITTED tCK# RECEIVED BY DATE PERMIT N0. <br /> INFO CASH <br /> r <br /> k <br /> + EH 13-241REV.1/651 3 742,"�� <br /> EH 1429 1 e / ��_111EEE <br />