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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6761 <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 /> Job Adpreu &Z City lot Size PM <br /> Owner's Name /� 5 +" Address Phone <br /> Contractor's Name /_L1-I r icensa No. , � Phone <br /> TYPE OF WELL/PUMP; -- NEW WELL 0 WELL REPLACEMENT DESTRUCTIOn, J <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER C <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 s1 <br /> '- Industrial 0 Open Bottom Cl Manteca Dia, of Well Excavation Die, of Well Casing '\ <br /> - Domestic/Private C Gravel Pack 7. Tracy Type of Casing Specifications <br /> Public C Other 0 Delta Depth of Grout Seal Type of Grout �I <br /> " Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by_ <br /> Repair Work Done C Type of Pump N.P. State Work Dona <br /> Well Destruction C Well Diameter Sealing Material(top 50') r � <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION f 7 (No septic system Permitted if public sewer is <br /> available within 200 fast.) <br /> Installation will serve: Residence. _ Commercial-L--Other �� A ��� �npp ` <br /> Number o1 living�•nita:_ Number of bedroomsaf T_ _ C r <br /> Character Of soil to a. zpth of 3 fmt:.,rp�+-•+--:F 41'T— ,,� Water table depth <br /> SEPTIC TANK n Type/Mfg �.aX� Lam'46L Capeciry�k._ - No. Compartments <br /> PKG. TREATMENT PLT.E; Method of Disposal <br /> Distance to nearese Well Foundation Property Line <br /> LEACHING LINE No. 8 Length of liras ¢�.j/ �Ot"Ifirt 1z-11Ls <br /> FILTER BED ,r\Distance to nearest: Weil 4"C Foundation j'N Property Line <br /> SEEPAGE PITS Depth _Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby candy that I have prepared this application and that the work wilt 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 /> -,ploy any person m such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cenifien the following:"I certify that in the purformance of the work for which this permit is issued,I shall employ pemons subject to workmen's compensa- <br /> non laws of California." <br /> The applicant must ca I for all requii@d impeeOons. Complete drawing on re area side. T <br /> <-gnen x "_!_I_!_ Lc.":lyei.. — Title:,,..1.6�-�'�--E. Date: 1P/ <br /> T I FOR DEPARTMENT UCE ONLY <br /> Application Accepted by Date <br /> i <br /> Pit or Grout Insppcnon by Date_ Final In tion by Data <br /> Up j Ly <br /> Additional tprnrr,pnts: <br /> Srk 466"iI7MI Lodi" 363"3621 C Manteca 7104 - Tracy 2366'i65 <br /> Applicant Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 51k., CA 95201 <br /> [fF GK v-�T--- <br /> INtO =MOUNT DUE AMOUNT REMITTED GASH RECEIVED B'/ DATE PEP-IT N0. COPY <br />