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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E/,HAZEL T ON , VE.,..STO.CKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ►; <br /> (Complete in Triplicate), ,,, s . . <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. 1962 for well/pump and:the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> CJ I ��✓%RI�� City J .L�..� Lot SizeO a(Fi Ot9 PM <br /> Owner's Name AddressPhone <br /> Contractor_ Lc'+:W)D Address LPtP-�q-A1. License No. <br /> r - a-7& Phone 1 " J 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP IN�TALLATION-Q--------SYSTEM-,REPAIR­E]==7=:_;-_ 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 <br /> E ❑ Industrial ❑ Open Bottom ❑,Manteca—Dia.-of.Well.-Excavation— Dia. of Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ 'Eastern Surface Seal Installed by <br /> C Repair Work Done ❑ Type of Pump H.P. '` 4 f State Work Done _ <br /> a <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth ! Filler Material (Below 501 { l� <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residencei' Commercial_ Other <br /> Number of living units: --/— Number of bedrooms_lel <br /> Character of soil to a depth of 3 feet: L 1 Water table depth <br /> SEPTIC TANK [� Type/Mfg FIB.E%;` 674AS-5 Capacity J1-a O— No. Compartments <br /> PKG. TREATMENT PLT. ❑ y °``�;% r Method ofDisposalf ' <br /> fir �o t <br /> Distance to nearest: Well Foundation �!'t.y Property Line <br /> l LEACHING LINE ❑ No. & Length of lines YrTotal length/size - l <br /> k t .: <br /> FILTER BED ❑ Distance tone sq S•,1l lig Foundatiorh - }-* Property Line <br /> r - ��, r § <br /> SEEPAGE PITS ❑ Depth C +Numbger <br /> SUMPS El Dista --tt06etreat- Well- Foundation Property Line <br /> r DISPOSAL PONDS ❑ � "+: + t <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_Califor�ia-"Contractor's hiring or sub-contracting signature <br /> I 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 /> . <br /> The applicant must call for all required iPspections. Complete drawing on reverse side. 11 <br /> Signed XS '�"Yr/f Title: Date: Z'a• <br /> FOR DEPARTMENT USE ONLY <br /> .......11.....uvj <br /> Application Accepted by Date Area <br /> ih <br /> Pit or Grout Inspection bc�— Date Q, r,n, t`r Final.Inspectio`n_i y <br /> Addifional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 6395 - <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 CK RECEIVED BY DATE PERMIT'NO. r <br /> INFO CASH <br /> + EH13-24IREV.t/95) 6-7/ 3 S3 ` <br /> EH 1426 J <br /> r <br />