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�f rl C <br /> # APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L-,1 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <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 <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 Sari Joaq, <br /> Local Health District. <br /> Job Address 3 a R E. Co-QAtyA <br /> . _ Lot Size �-v <br /> !, PM <br /> Owner's Name�`�='�Q' l a�) �t d O1Ci� Address 1 0 <br /> ����,,`` //TT Phone c� <br /> ContractoE/ut. �tJ l 2 Address P'(7" R07e7k'7 G"t License Noj;�.-� 3�j6 j/OS <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> rl FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C (CATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> j O Domestic/Private O Gravel Pack ❑ Tracy .Type of Casing Specifications <br /> t ❑ Public ❑ Other O Delta <br /> rl Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation -_.Approx. Depth O Eastern Surface Seat Instatled by <br /> rl <br /> Repair Work Done O Type of Pump N.P. State Work Done <br /> Well Destruction O Well Diameter Seating Material(top 50') <br /> Depth Filler Material(Below 5(r) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION O QESTRUCTtON❑ (Notrc <br /> SeP 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 f <br /> Character of sol to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity "�4 <br /> / 0 No. Compartments t <br /> PKG. TREATMENT PLT.O t r Method of Disposal <br /> Distance to nearest: Wepta Foundation- Property Line��, <br /> F1LEACHING UNE i9__'No.& Length of livres Total Length/size <br /> FILTER BED O Distance to nearest; Wellt rT <br /> �� Foundation. property[.Erie <br /> SEEPAGE PITS [Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well OOr Foundation �. <br /> f �---��r Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin county ordinances,state laws, ant' <br /> rules and regulations of the San Joaquin Local Heafth District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the'perfonnence of the work for which this <br /> permit is issued, t shall no <br /> employ any person in such manner as to become subject to workman's campensatiori laws of California."Contractors hiring or sub-contracting signatun <br /> F1 certifies the following:"!certify that in the performance of the work for which tfiis permit is Issued,1 shop employ persons subject to workman's corn <br /> tion laws of Catifomia." pensa <br /> The applicant mu call for at ui inspections. Complete drawing on r/eversee side. <br /> Signed Tide:, U 1 _ Dater J <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by Date <br /> Area <br /> or Grout IrtsPection.by Oatei Final Inspection by <br /> Dat <br /> Additional Comments _ z; <br /> O sik 4W-6781 L'1 Lodi 389-3621 U Manteca 823-7104 ❑ Tracy 8a5 g5 " <br /> Applicant-Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I AMnUMT nuc AUniiuY oc.urrcn I CK r _ — <br /> Fit <br />