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APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH.litSTRICT_. <br /> 1601 E, HAZELTON.AVE--STOCKTON, CA 4 <br /> Teleph one'(209)-4366-6781- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 147 <br /> I (Complete in Triplicate) ENVIROMENTAppLHEALTH <br /> Application is hereby made to the San,Joaquin Local Health District for a permit to construct and/or install the wt[rIF-tte?41 4At1 ��//ACT%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 /> Q <br /> Job Address D Y/ � l Le r`:J City L—d b Lot Size .PM i <br /> l�us-LE <br /> � Owner's Name`c..T��,�,v y � Address .57'17 Ve:;­ Phone <br /> UJ►fJ <br /> i <br /> Contractor JOU r Of— &oo Address/ IV 4011.AC ' License No+(b.lPhone - <br /> TYPE OF WELL/PUMP: NtW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRS OTHER n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL FLD. PROP. LINE <br /> FOUNDATION = AGRICULTURE WELL — = OTHER WELL PITS/SUMPS- — +F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mariteca _ T Dia. of Well Excavation Dia. of Well Casing <br /> ADomestic/Private ❑ Gravel Pack ❑Tracy Type of CasingSpecifications a. <br /> M Public r Other CI Deht # Depth of Grout Seal Type of Grout c ; <br /> I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done_�t°/�liR VM <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1 DESTRUCTION 1-1 (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence= Commercial_ Other (tom <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ _ Water table depth <br /> SEPTIC TANK O Type/Mfg - Capacity ' No. Compartments _ M <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation.____ Property Line r <br /> LEACHING LINE 0 No. & Length of lines __ Total length/size—__ <br /> FILTER BED O Distance to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS I I Depth _---Size _ Number (� <br /> - <br /> _—SUMPS--. --.3.L-1—Distance to nearest: Well Foundation _ --Properly rine <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, ane <br /> rules and regulations of the San Joaquin Local Health District. { <br /> Home owner or licensed a nt's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in ch net as o IeCOme su to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following "1 c that the pe nc of the work for which this permit is issued,I shall employ persons subject to workman's eon4pensa- <br /> tion laws of Californi ' <br /> The applicant t for all d Complete drawing on reverse side. <br /> Signed X Title: I11 r► h �'�IQ Date: I A''7— 7 <br /> r <br /> r O EPARTMENT USE ONLY <br /> Application Accepted by Date b - Area D `-• (" <br /> { Pit or Grout Inspection by Date Final Inspection by �/ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 O Lodi 369-3621 0 Manteca 823"7104 O Tracy 835-6385 <br /> Applicant - Return all copies to: Fnviromm�ntel Flealih Permit/Services 1601 F. Hazelton Ave., P.O- 6ox 2009, Stk., CA 06201 <br /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMiT'NO• <br /> EH 13L211REV."`15) '� 9—&7 e 7-3 . <br /> EH ti-26 a <br /> i <br />