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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCACHEALTH DISTRICT <br /> 1601 E. HAZEL—1 ON AVE., STOCKTON, CA <br /> Telephone-(209) 466-6* <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 Ryles and Regulations of the San Joaquin <br /> ,'Local Health District. <br /> Job Address City' tLot Sze PM <br /> "j,' T <br /> Owner's Name Addregs E(Q.cc -Phone <br /> Contra C��Xddress N5A License No. Phone�t5wme_ <br /> TYPE OF WELL/PUMP; NEW WELL 0 WELL REPLACEMENT El DESTRUCTION 13 i <br /> PUMP INSTALLATION 71 <br /> SYSTEM REPAIR,0 OTHER 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,S'WER'LfN'- <br /> E ESDISPOSAL FLO.— PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMP'S <br /> INTENDED USE TYPE OF WELL L.-PROBLEM AREA AjCONSTRUCTION SPECIFICATIONS <br /> 1-1 Industrial 0 Open Bottom EJ MantecafDia. of Well Excavation Dia. of Well Casing <br /> EJ Domestic/Private 0 Gravel Pack E) Tracy Type of Casing Specifications <br /> El Public 0.Other '0 Delta Depth of Grout Seal- Type of Grout <br /> [D Irrigation --Approx. Depth ET Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. <br /> State Work Done <br /> Well Destruction 0 Well DiameterSealing Material (top 50') <br /> Depth l Y Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION 17 DESTRUCTION E (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence orpmerciai Other <br /> Number of living units: - Numbercf Wbedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK LL-1 Type/Mfg J fir` I Capacity No.No. Compartments <br /> PKG. TREATMENT PLT. 0 <br /> 7 Method of Dj�u�al <br /> Distance to nearest: Well X5 00 Foundation-c2'() Property Line (a!5 r <br /> LEACHING LINE EJ No. & LengthLTotal length/size <br /> FILTER BED <br /> EJ Distance'to nearest: WW�� Foundation Property,Line 42C) <br /> SEEPAGE PITS LJ Depth Size r Number <br /> --sumps 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 17 <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 '�nd)regulations of the San Joaquin Local Health Disiricri., <br /> Horneowner-or ii6ehsed 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 /> emplo any person in such manner as to become subject to workman compensation laws of California."Contractor's hiring or sub-contracting signaturd= <br /> certifies the following: "I certify that in the perfoirmancel&the-work for which this permit is issued, I shall employ p6rsoni subject to workman's compensa <br /> tion laws of California." 11 . <br /> The applicant ust call for all requireinspections. Complete drawing on reverse side. <br /> r <br /> tli: <br /> Signed )710 cl-An 71 Ti <br /> U <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by CA4--- <br /> Date Area 06 <br /> Pit or Grout Inspection by Date Final I nspecti6n by: Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 389-3621 El Manteca 823-7104 0 Tracy 835-6395 <br /> Applicant- Return all copies to: Environm6ntail Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DU.E CK <br /> INFO AMOUNT REMITTED-- CASH RECEIVED BYDATE PERMIT`NO.' <br /> + EM 13-24(REV.I/A 5) 4L <br /> 00 <br /> EH 1428 <br />