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s , <br /> APPLICATION:FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-$781 <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 /> Job Address _ Y� / _ City r9Co"t�5ize PM <br /> Owner's Name �A u 15 7/11-1 o �D lr7Address' l Phone <br /> Contractor Address ti ' s License No. X% _one�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELr REPLACEMENT ❑ DESTRUCTION ❑ <br /> � .{t PIMP INSTALLATION ❑ S SYSTEM-REPAIR ❑ OTHER LJ e <br /> DISTANCE TO NEAREST:•.SEPTIC TANK ' SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom. ❑ Manteca Dia-of-Well,-Excavation- - Dia. of Well Casing t - , <br /> ❑ Domestic/Private ❑ Gravel Pack ❑)Tracy Type of Casing j Specifications <br /> E <br /> ❑ Public D Other 'Y.ZJ ❑ Delta Depth of.GroutSeal ' Type of Grout �+ + <br /> ❑ Irrigation _JApprox. Depth ❑ Eastern Surface Seal Installed by' <br /> Repair Work Done ❑ Type Pump t ~`�' H.P. <br /> yam,.---- State Work pone <br /> Well Destruction ❑ Well Diameter = Sealing Material (top 50') <br /> Depth - Filler Material (Below_50')� - ' <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> • � available within 200 feet.) <br /> Installation will serve: Residence_t Commercial_ Other : i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:: �* •, k - - r t ' <br /> b p _ � - V1/ater`table,deptfi <br /> SEPTIC TANK ❑ T e/Mf `f^i - '% '' � "` �` <br /> YFt 9 Capacity_ No. Compartments <br /> PKG. TREATMENT'PLT. 17 Method'of1Disposa! <br /> Distance to nearest: Well Foundation 1 Property Line <br /> F \ <br /> LEACHING`LINE' No. & Length of lines I ��1'.Total length/size <br /> ,:FILTER BED a [7Distance to nearest. ell : _ 7Foundati nProperty Line=`_ _!� <br /> SEEPAGE PITS ❑''Depth <br /> SUMPS ❑ Distance to nearest .Well Q� fFounda`tion " 'C�'�/i - <br /> �*' !. �— Property Line J <br /> DISPOSAL PONDS ❑ 't ( �' r <br /> I hereby certify that I have prepared this application and�that the work will-lie�done^in°accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District,,,,., <br /> ;.. . �. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permt'is7issued, 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 subcontracting 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 <br /> The applicant call for all require - pectin s. Complete drawing omreverse side. s <br /> Signed X fle: ±,r i. tt' L <br /> Date: ._ <br /> ,;..,.,.n•...�.—.*-..�,....,a...,-s�>......-.—.--.-.r.-�r..-�-.-..-r,«--a..-�<,- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date .�U''ZZ"g6, a oe <br /> i <br /> Pit or Grout Inspection by Date Final Inspection Dat% <br /> Additional Comments: <br /> C7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Ij Tracy 835-6385 , <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 <br /> YFEE "AMOUNT DUE AMOUNT REMITTED G H RECEIVED BY DATE PERMIT'NO. <br /> -+ EH 13-24(REV.1 85) :r _ 4 <br /> EH 14-28 .. C7 `-$ �.. '�-1�C• �O d <br /> 4 b <br /> ' F <br /> 135 <br /> - — �..r.-'^ � � ti... -.a .ice+••==_ ,.. - .�` s,r ,r-.. _. .... - - - �1. <br />