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x APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZE T ON AVE„ STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> •i 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 �` r � City..L1 mb __ Lot Size PM <br /> Owner's Name Le FF, Address Phone <br /> Contractor,LA- a-'► t- 1 7 t R�_L __ Address tJ License No. bane <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPANSTALLATION ❑" --SYSTEM-REPAIR.❑.,'"."'_--'-'"""'""`'.OTHER'❑"_'^°„” <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑ industrial s Cl.Open.=Bottom IJ-Manteca__ Well-Excavation.------- -- Dia. of..Well-Casing_, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy' Type of`Casing Specifications <br /> ,M Public ❑ Other f] Delta Depth of Grout Seal Type of Grout <br /> Fs <br /> I I Irrigation —.-Approx. Depth 11 Eastern- Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump H.P. State.Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth filler Material Melow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION HLPAIR/ADDITION i l DESTRUCTION l I Wo septic system permitted if public sewer is <br /> 1 available within 200 feet.I <br /> l r Installation will serve: Res-deuce commercial Other r} f <br /> Number of living units: Number of bedrooms <br /> f Characterof soil to a depth of 3.feet: V-A _ Water table depth <br /> i <br /> SEPTIC TANK t NCS-Type/Mfg: - Capacity No. Compartments . 71 <br /> PKG. TREATMENT PLT. ❑ _ ' Method of Disposal - <br /> Distance to nearest: -Well ndation =Property Line <br /> � �� Fou . <br /> iR <br /> LEACHING LINE & Length of lines -> / D I r'I-otal length/size <br /> FILTER BED ❑ Distance to nearest:. Well " '°' —TFoundationProperty Line <br /> SEEPAGE PITS LL..6 pth. Size Number <br /> SUMPS ❑ Distance to nearest: WellFoundation `Property Line <br /> r DISPOSAL PONDS n,., r° 1 <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 workmari's-compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ertifies the fallowing: "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 sof California , t <br /> The aplica pst ri al �uiredns�pein Y mplete drawing on e <br /> reverse si . _ <br /> Signe Title: Date: <br /> FOR,DEPARTMENT USE ONLY <br /> Application Accepted by Date Area l� <br /> Pit or Grout Inspection by Datte 16- inal Inspec ion by-e • �.�. � Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O j Box 2009, Stk., CA 95201 <br /> FEE I INFO MOUNT DUE' AMOUNT REMITTED _CASH RECEIVED By; DATE PERMIT NO. <br /> ' t <br /> + EH 1324(REV.t i n 5) <br /> t EH 10-2e <br /> l <br />