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v � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA <br /> Telephone-(209) 466-6781 Q <br /> D o � <br /> PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Heand/or,install the work herein described.This application is <br /> Health District for a permit to construct a <br /> made compliance with San Joaquin County Ordinance No.549 for sewage or No.1662 for well/pump and,the Rules and Regulations of the San Joaquin <br /> Local Health Dist�rict� �Q Z 4:> <br /> t l i C- (a +���1 p Cit �ot S48 PM <br /> Job Address !! '' ��C <br /> 1 t JL. `-^"A11dr�ss '2 1N1 � Phone t <br /> Owner's Nam _ s . . 11 . . . ... .- - <br /> .:. LL <br /> License Noy�'g O� Phone .���� <br /> I �y s y Pcrtw tv r�iJ Z._Address <br /> Contr <br /> NEW WELL_0 WELL flEPLACEMENT.❑,. ,� DESTRUCTION ❑ _, L <br /> TYPE OF WELL/PUMP: - SYSTEM REPAIR Q OTHER ❑ <br /> PUMP INSTALLATION _ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCETO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D� of Well <br /> Casing `+ <br /> ❑ Industrial ' Q Open Bottom L7 Manteca Dia. of Well Excavation Dia.ofcati ll <br /> `. Type of Casing <br /> jns <br /> Domestic/Private Q Gravel Pack' O Tracy Type of Grout <br /> II fl Public ' F1 Other C1 Delta Depth of Grout Seal <br /> I I Irrigation r —Approx. th l 1 Eastern Surface Seal Installed by <br /> j H P11 "lik <br /> Stats Work Don <br /> Repair Work`Done _U Type of Pump <br /> t Well Destruction ❑ Well Diameter Sealing Material [top 50') <br /> Depth Fitter Material (Below 601 <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIRlADD1TION 1.1 DESTRUCTION I I alvail bleiwithina200 feet/ ed it public sewer is <br /> .f <br /> Installation will serve:' Residence Commercial— Other — <br /> Numbe%Df living units: Number of bedrooms Water table depth <br /> Character•of soil to a depth of 3 feet: <br /> e/Mf Capacity No. Compertmenta <br /> SEPTIC TANK.' ❑ TYP 9 A Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of lines -Total length/size pro Line <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Reny ` <br /> r <br /> Number <br /> SEEPAGE PITS I 1 Depth Sixe <br /> SUMPS Ll Distance to nearest: � Well Foundation Property Line <br /> . •s <br /> DISPOSAL PONDS ❑ <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 and regulatioh�,p4the San Joaquin Local Health District. <br /> Home owner or licensed'atgent'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."Contractors hiring or sub-contracting signature <br /> certifies the fo,"ing:"1 certify that in the Radar once he work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of alifornia." <br /> The applic t must call f elV yired in one. plate drawing averse side. n y 'rJy <br /> Date: <br /> f1� / <br /> Signed <br /> I FOR DEPARTMENT USE ONLY <br /> Date, JZ' Area <br /> Application Accepted by z.— .• F . • - <br /> IFinal Inspection by Data <br /> Pit or Grout Inspection by Date <br /> Additional Comments: Tracy 0335 6385 <br /> Cl Stk 466-6781 ❑ Lodi -3621 �71Manteca <br /> h PermitIServices.1601 E. Ha:etton Ave., P.O. Box 2009, Sik., CA 95261 <br /> Applicant,- Return rill copies to: Environmental Healt <br /> FEE ( GK RECEIVED 8Y DATE PERMIT N0. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> r EH 14-24(REV.I 15 <br /> EK 1429 <br />