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141 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �# <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> (PERMIT EXPIRES TYEAR FROM DATE ISSUED 1,1 <br /> Y (Complete in Triplicate) <br /> I <br /> Application is he,eby 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 t <br /> Local Health District. i <br /> r•� Ii <br /> 1 ! <br /> Le I <br /> Job Address �" City � dim <br /> eSize PM <br /> 1� 8 <br /> Owner's Name ress / ®, -" Phone <br /> I <br /> ContractorP dress r-- ense N sya, ne Q <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ �' <br /> Y <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE 1 <br /> + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> __ _ _ _.C- -- <br /> ❑ Industrial ❑ Open Bottom ❑—Manteca L� Dia. of Well Excavation Dia.a. of INeH�Casing <br /> Q Domestic/Private ❑ Gravel Fad Tracy ==-a_ T pe-of Casing- Specifications }f ` <br /> r f"M Public) Ll Other f.1 Delta Depth of Grout Seal Type of Grout It <br /> 4 t pa „ • _ H' <br /> r 41 <br /> �Y�wr i�l�lrrigation -Es <br /> _..Apprbx. Deph � ' ter�nSirt�cSed1`ntalled bye <br /> Ik <br /> € a �Reparr Work Done ❑ a'Type of Pump # ' H.P. State Work Done <br /> Well Destruction ❑ , Well Diameter Sealing Material (top 501 <br /> st 1 Depth r Filler Material (Below 50'1 <br /> --TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAIR/ADDITION I I .DESTRUCTION o-septic system permitted if public sewer is i <br /> Ovailable within 200 feet,I ' <br /> Installation will serve: Residence_ Commercial— Other <br /> ( Number of living units: Number of bedrooms t <br /> It <br /> l Character of soil to a depth of 3 feet: l ` """'"'"rJater table depth <br /> SEPTfC TANK 40 Type/Mfg Capacity No._Compartments <br /> 4 R <br /> PKG. TREATMENT PLT. 17 'f r y � j �'+ Method f Disposal <br /> Distance to nearest:. Well Foundation Property Line* IE <br /> LEACHING LINE ! ❑ No. & Length of lines Total length/size Ij <br /> FILTER BED ! © Distance to nearest: Well Foundation Property Line II <br /> SEEPAGE PITS ['I Depth - Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ If- <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 apy person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for wFich-ibis permit is issued, I shall employ'persons subject to workman's compensa- <br /> tion-laws'of <br /> The app <br /> t m cel f all requir in ions. Complete drawing on r arse side. <br /> .+ Title: f l K� Date:. _ i'L l <br /> Signed°JC ' ti <br /> .fit. FOR DEPARTMENT USE ONLY 7 /� <br /> Application Accepted by Date ��'Zr Area { <br /> Pit or Grout Inspection by `I bate Final Inspection by <br /> Data/��6 <br /> l <br /> y c14 ! <br /> Additional Comments: __ .... <br /> ❑ Sik 466-6781 ❑ Lodi 369-361 ❑ Manteca 823.7104 ❑ Tracy 835-6385 <br /> r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 951201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> s' <br /> ♦ EH 13-24{REV.t/H 51 i <br /> EH,4.26 - � �]t77 <br /> 17 <br />