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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 Si 0 1 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUEDi�NVIRLOINFMI! ri-, A! T' <br /> C <br /> (Complete in Triplicate) P E R iN`,:1' r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insoli'the work herein described. This applica"I.-n is <br /> PI made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaqu <br /> Local Health District. <br /> 1'171 �7 <br /> Z <br /> Job Address __Z Z,:4-, / City Lot Size PM <br /> Owner's Name N No n Address 7 Phone <br /> Contractor 4fJ1vV4 _Address <br /> &)4 d(Ajt�-YX License No. _Pho <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT [I DESTRUCTION 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 111 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLO.-- PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF;WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial 0 Open Bottom M rftnteca Dia. of Well Excavation Dia. of Well Casing <br /> [-I Domestic/Private 0 Gravel Pack n Tracy Type of Casing Specifications <br /> Piebtic Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I Irrigation ___'Approx. Depth E I Eastern Surface Seal Installed by <br /> Repair Work Done iJ Type of Pump H.P. State Work Done PC <br /> if -- I J J <br /> Well Destruction U Well Diameter Sealing Material Itop SO') <br /> Depth Filler Material tBelow 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: _� Number of bedrooms <br /> Character of soil to a depth of 3 feet- Water table depth <br /> SEPTIC TANK Cl Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. n Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE Cl No. & Length'of lines Total tongth/size <br /> FILTER BED E-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS n <br /> I hereby certify that I have prepared this appfication 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signafor- <br /> certifies the folio 'I cortify that in the performance of the work for which.this pe rmit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws f a f �n... <br /> The appli nt �, call for all to?9'ed inspeql�lns. Complete drawing on rev rse Sid <br /> J, <br /> Title. r . a_� <br /> Signed X 'A <br /> "' rt—eie 0 A__J Date: <br /> 44 FOR <br /> DEPARTM NT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by If /,C:2dcg✓ DateA'7—? <br /> Additional Comments: ),W edl- <br /> 0 Sik 466-6781 0 Lodi 369-36521 0 Manteca 923-7104 U Tracy 835.63i5 rl <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 962011v,.� <br /> IFEE CK i <br /> AMOUNT DUE LINT REMIT-TED RECEIVED BY <br /> Amo DATE ?E MIT'NEO CASH <br /> E Ft 13-24 IREV. 51 <br /> r <br />