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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON 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 weOpump and the Rules and'Reg`ulptions of the San Joaquin <br /> 3 <br /> Local Health District.. . <br /> Job Address Z L490'­ O U 04V City Lot Size `l�Cti°C PM <br /> Owner's Name r Address- P.horae � <br /> !Contractor's Name ��v c$ License No. 4?y.� T Phone <br /> -06.0-7 <br /> -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION ❑ " <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑°"� --- �y <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEINER NESS r DISPOSAL FLO. PROP. LINT C <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT$/.SUMPS Q <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOIgS' , , <br /> `❑ Industrial }.��.❑_Open Bottom ❑ Manteca; " Dia. of Well Excavation :,: Ora , f Well 'Casing.,'- <br /> 4 f❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifcations z <br /> l❑ Public ❑ Other ❑ Delta 4 ~ ,.Depth of Grout Seal '�- :�ti Type_offGGrapt <br /> y s. .. <br /> t 1❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed"b f , <br /> ?Repair Work Done ❑ Type of;Pump ,,`H.P. State Work Dong <br /> :well Destruction C1 Wall Diameter <' Sealing Material (top 50'! <br /> Filler Material (Bela ') <br /> -_. # Di .' eptF. - <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septk'system permitted if public sewer is <br /> _ available within_ 200 f€€eet.i <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: �_ Number of-bedraor'ns -43 / <br /> Character of4soil-to•a-depth-of-31feet: ti I Water table depth <br /> SEPTIC TANK El TypelMfg� Capacity No.Compartments <br /> 35 - PKG TREATMENT PLT. ❑ Y Method of Disposal <br /> —Distance-to-nearest:—Well------------Foundation—Property-L-ine-- ==L <br /> ',LEACHING LINE L7 No. & Length of lines r � — Total length/size., <br /> FILTER BED ❑ Distance to nearest: Well ­3-1? f Foundation /40 Property Line.2. <br /> SEEPAGE PITS [Depth Size 3 J Number, <br /> y.f :f <br /> SUMPS �� ❑ Distance to nearest: Well Foundation~' ` Property Line t ' <br /> DISPOSAL PONDS ❑ <br /> I hereby artily that I have prepared this application and that the work will be done in accordance wRli'San Joaquin cou�ty-ordinanras,^state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall'not M <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hirino or sub-contracting signature <br /> certifies the following:"I aert'rfy 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." �.�•— _ ». •- �-^^ -- �'- 1 <br /> The ap Ii pall for al! required Inspect one. Co late drawing on reverse sid <br /> Signed Title: / - Data: <br /> i r � <br /> FOR DEPARTMENT USE ONLY <br /> . T - Data Area <br /> Apd <br /> pl!cstlon"Accejsted by , r <br /> Pit or Grout Inspection by �'`~ Date Final Inspection by Date L�-- <br /> i Additional Comments: ! <br /> ❑ Stk 4664M1 ❑ Lodi 368-3621 ❑ Manteca SZ3-7104 ❑ Tracy 83546385 j <br /> Applicant- Return all copies to:'Envlronmental Health Permit/Services 1601 E. Hazelton.A,ye., P.O. Box ZOos, Stk., CA 96201 <br /> FEE .AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE � PERMIT'NO. <br /> D <br /> INFO <br /> + EH 13-24 IRM 10M) <br /> EH 1429 :r. _ <br />