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APPLICATIOWFOR-PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> .- A-C <br /> Job Address Q f /7 City Lot Size gg M _ PM <br /> Owner's Name �% 04A-1. Address 3 CJ UIQ J A Phone <br /> 4 <br /> Contractor A Address.. /Yy AdT�+,4_License No 2✓t 5 Phone �{ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing - +s Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal "+ Type of Grout <br /> ❑ Irrigation1- <br /> ---Approx. Depth ❑ Easterni Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P.' t State Work Done_ C <br /> Well Destruction C1 Well Diameter �ealing Material (top 50') <br /> Depth Filler Material'(Below 501. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (Nd septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-J—­'�Co4rnercial Other <br /> Number of living units: 4— Number of bedrogms .�- <br /> Character of soil to a depth of 3 feet: t - m - WfffW-table depth / <br /> SEPTIC TANK Q Type/MfgCapacity.,w No. Compartments <br /> PKG. TREATMENT PLT. ❑ r y ��-- Method of Disposal <br /> Distance to nearest: Well U Foundation Property Line SCJ <br /> LEACHING LINE [ No. & Length of lutes � ' o Total length/size � 0 7— <br /> FILTER BED ❑ . Distance to nearest: Well:; Q!...-.rFoundation_gj '�7`Property Line <br /> SEEPAGE PITS ❑ Depth Sizes Number <br /> SUMPS ❑ Distance td nearest: Well { Foundation Property Line <br /> DISPOSAL PONDS E <br /> I hereby certify that I have prepared this application andithat the work wi0be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. '�. y� M _. _ , <br /> � <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." Contractors hiring or sub-contracting signs u <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 /> The applicant must call 2foralrequired spections. Complete drawing oa''r"everse side.40Signed X Title: ! ��ra��.. .,._ ( Date: �� ? <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by V 11%CJL _ T Date �� Area <br /> Pit•or Grout Inspection by Date Final Inspection by�MC <br /> r <br /> Additibnal Comments: <br /> ❑ Stk ..y.9_ 66=6781 O Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 <br /> App`Iicr . <br /> ant- Return ali copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk CA 952btFEECK , <br /> ' INFO- AMOUNT DUE _ .AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. <br /> + EH -24 IREV.t i R 51 <br /> 14 <br /> EN 14-28 v <br />