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-4 } <br /> 1`t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 , . w : . <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> c <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein e4escr6ad.This appYratlon i is tit <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.IBM for well/pump and the Rubs and Regulerbrr of Ifr Berl Joaquin <br /> : Local Health District. <br /> Job Address � <br /> �• City_ Lot Size - <br /> Owneis Name - .+�SC U Address / phone. <br /> .. <br /> 4)"t.,.i, <br /> Contractor �`o-� "fin Address "j`�O -l/ -'�j'4'�2 r� 'cense No. f�s3y Phone <br /> TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION v SYSTEM REPAIR C OTHER ❑ <br /> ( DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES - DISPOSAL FLD. PROP. LINE y� <br /> F AGRICULTURE WELL _ OTHER WELL PITS/SUMPS v; <br /> I INTENDED USE TYPE OF WELL PROBL CONSTRUCTION SPECIFICATIONS <br /> Y <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Die,o csvation - Dia.of Well Casnq <br /> F ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Carting SpeciFicatioru <br /> `s. <br /> 13 Public - ❑ Other ❑ Dolts Depth of Grout Seal Type of Grout <br /> } ❑ Irrigation _-.pprox. Depth D Eastern Surface Seal Installed by i ^ ' <br /> ± Repair Work Dore C Type of PumpH.P. State Work Dona c <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 „ t ,7 yy� <br /> t - Depth ' Filler Material(Below 501 t <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION DESTRUCTION D (No septic system permitted if pubiw sewer is 1 t e T <br /> available within 200 feet.) 9J2 [- <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units:_ Number of bedrooms <br /> Character of so to a depth of 3 leer. - Yteter table depth <br /> y,- SEPTIC TANK - ❑. Type/Mfg __ Capacity No. Compartments - <br /> . PKG. TREATMENT PLT.M - Method of Disposal <br /> Distance to nearest: Well__ Foundation Property Line <br /> ati <br /> LEACHING LINE _ 5No. & Length of lines _ �� FT Total length/size 9� fT• ,-Y <br /> FILTER DED ❑ Distance to nearest: Well - Foundation Property Line <br /> SEEPAGE PITS C Depth Sim. Number <br /> h <br /> .SUMPS ❑ Distance to nearest Wall Foundation 7t9 Property Line .. <br /> DISPOSAL PONDS C <br /> x: <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances stare)ewe a•xf <br /> rules and regulations of the Sen 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 H 4ausd;I shall rot •fin . <br /> - employ any perwn in such ma er ea to beeume subject to workman's compensation Ism of California."Contractors hiring or eub-dontraetfrp skgnawn, <br /> eeri8ies the=0110,0 n 'I a het in the performance of the work for which this rmit is issued,I shall employ ti <br /> g:• pe p Y persons subject to workmen's pgnpenta ! a✓¢ <br /> - tion Paws of California." <br /> The applicant mus:c 1 174WU;red '+'p`eclio omplete drawing on reverse side. " <br /> r� s <br /> Signed)L / Title: s <br /> - FOR DEPARTMENT USE ONLY <br /> Apppcation Acccptod by cf\— Date_ oC Area <br /> Pit or Grout Inspection by Date Final Inspection byr^ /• '2f Da;e <br /> ditional Comments: <br /> C Stk 466-6781 C Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 —_--- <br /> Applicant- Return all copies to: Environn,,tal Health Permit/Services 1601 E. Hazebon Ave., P.O. Sox 2009, Stk., CA 95201 <br /> FEE <br /> NFD AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE RFRMII NO. <br /> FH taN(REV,vs sl `l <br /> EH t43e I O —X / [wv/ 7,21.�J <br />