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.i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> k: },^ta (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 /> Ir 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 /> 1 Job Address 17�0 City Lot Size mgK PM <br /> V`/ 111C,0'4041 <br /> / p r <br /> Owner's Name �� P-lAil Address Me. 1 ! hone _ 3460' <br /> Contractor LAddress � � License No. � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑., - <br /> PUMP INSTALLATION L� t SYSTEMIREP41R ❑ OTHER) <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES + i' -- _DISPOSAL FLD -O3 PROP. LINE r� 11144 <br /> 4 l FOUNDATION 'Y AGRICULTURE WELL '�- OTHER WELL PITS/SUMPS-tEO' . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 <br /> 14)tadL�I <br /> stria) )(Open Bottom Ll Manteca Dia. of Well Excavatio Dia. of Well Casing <br /> ❑ <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing ,, Specifications <br /> •Public ❑ Other LJDelta Depth of Grout Seal Type of Grout <br /> }krigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ih eipair Work Done Type of Pum H.P._ State Work Done <br /> 1 i; Well Destruction 71 <br /> Well Diameter Sealing Material (top SO-) <br /> 1 Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is "Q <br /> ` 1 ') ,, available within 200 feet.h '1 <br /> Installation will serve: Residence_;Commercial— Other <br /> Number of living units: Number of:bedrooms f '' x <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg rt ' Capacity No. Compartments <br /> L PKG. TREATMENT PLT. L1Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑'i No. & Length of lines r Total-length/size <br /> FILTER BED ❑'" Distance to nearest: Well 4 Foundation r = Property Line <br /> s r <br /> ' SEEPAGE PITS 11 . Depth Size Number <br /> SUMPS ❑P Distance to nearest: Well Foundation ; w. Property Line <br /> DISPOSAL_ PONDS ❑ . r <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander <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,1 shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant u call far all requir i pections. Complete drawing an ve13.side. <br /> �- <br /> i Ete: <br /> signed Title: <br /> FOR DEPARTMENT USE ONLY f� <br /> y Application Accepted by ? Date O Area <br /> Pit or Grout Inspection by Date Final Inspection y Date AV <br /> Additional Comments: D. <br /> © Stk 466-6781 Lodi 369- ❑ Manteca 823;7104 Tracy' , 6385 i <br /> 4.:. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton'Ave,'P.O. B 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM17'NO. <br /> INFO _ <br /> + EH 13- IREY.1/65) - © / t <br /> EH 1428 }�q Iv��1 <br />