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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i, PERMIT EXPIRES '!"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 /> Jab Address City Lot Size�-� r PM <br /> t � r <br /> Qom, !� I <br /> Owner's Name �7� Address� � <br /> `.v•! ��� Phone <br /> Contractor �/�iZI ZIC�t/ � Address Q: License No.d;V5—Y`5�hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINESDISPOSAL FLD. PROD. IJINE <br /> FOUNDATION AGRICULTURE WELL— OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> II - L <br /> i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excavatiori Dia. of Weil Casing \� <br />' ❑ Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications <br /> i <br /> (-1 Public Ll,Other Ll Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation Approx..D"6pth ` [-I Eastern w-•Surface Seal"Installed'&j. _ <br /> I Repair Work Done ❑ Type of Pump H.P. State Work Done4_ <br /> Well Destruction .❑ Well:Diameter Sealing Material (top 501 I <br /> Depth `' Filler Material !Below 50') <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i.]. -DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within,200 feet.) <br /> Installation will serve. " Residence�CQmmercial_ "tither' <br /> Number of living units: Number of bedrooms X f ; `fir`-' � n .. <br /> �a.lW <br /> Character of soil to a'depth of 3 feet: '" -� - Wates tabfe de"p"ih 1 ' <br /> ; _ y' ## <br /> SEPTIC TANK ❑ Type/Mfg- L �Capacity (hJD% No. mpartments <br /> PKG. TREATMENT PLT. ❑ dj f,L4li/t+17-c/ ij rMethod ol'Disposa ' L^ ` <br /> i Distance to nearest: Well 9.471 E Foundation r�- Property.Liner i ~ <br /> 1 Az' <br /> LEACHING LINE ; No. & Length of linesfe <br /> " T Total length/site <br /> 3 <br /> FILTER BED M Distance to nearest: Well Foundation�Q Propei't�lis Line <br /> f ' , <br /> r1 s—� <br /> SEEPAGE PITS I I :. Depths Size U Number <br /> SUMPS , Distance to nearest: Well Foundation �T Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this'application and that the work will be done in accordance with San Joaquih cdunty'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 workman's compensation laws of California."Contractor's hiring or sub-Lontracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons� bject toss forkman's compensa <br /> tion laws;of California." <br /> The applicant must call for II requirpd inspections. Complete drawing on reverse side. <br /> Signed X Title: —-_ le.. Date: <br /> #OR DEP MENT USE ONLY y� <br /> Application Accepted by Date f eat' ��� <br /> Pit or Grout Inspection by Date Final Inspection b 0Date�i7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca'-"823-71134 El Tracy. 835-6385 }; <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O:Box 2009, Stk., CA 95201FEE ` <br /> CK 0 <br /> INFO °MOUNT DUE AMOUNT REMITTEQ` .:,_. CASH RECEIVI Q BYNe .DATE PERMIT NO. <br /> _ 01 13-21(REV.I/H 5) <br /> aEFf 11 <br />