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`r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 11�� <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 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. ] r �L c 'r, <br /> Job Address 2 6 ,L 9—+ MA� O h AV. C/iN-L � Ipt Size I d ficlf5 PM <br /> Owner's Name�;_ ; L Address SWMOF Phone <br /> _ yl., 1/I 7 or;kil>,►�t'J_ <br /> Contractor 01:Sov1'RACehb2 . Address 9 AMA V License No.gL?8 Phone j <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ <br /> _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ,r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ey-` <br /> " ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> j Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Y available within 200 feet.) <br /> Installation will serve: Residence 4. Commercial_ Other <br /> Number of living units: _ Number of begrooms/ <br /> Character of soil to a depth of 3 feet: C/ ftd— (Q � Water table depth <br /> j SEPTIC TANK 7L Type/Mfg 'c4ST C0nC1 _ZCapacity �C V No, Compartments <br /> PKG. TREATMENT PLT. F 4 Method of/p6ISDosi <br /> Distance to nearest: Wel✓ O b0 Foundation Z Property Line L0 <br /> LEACHING LINE No.& Length of lines - - _ r - `"Tdtal length/size <br /> FILTER BED ,❑ Distance to nearest Well/12_0_�*_-Foundation _4Z?,7 z f` Property Line '1490 + <br /> SEEPAGE PITS ❑ Depth Size � cumber <br /> SUMPS ` » Distance to nearest: Well FoundatiQM O `0 Property Line <br /> DISPOSAL PONDS 1:11�1 <br /> 1 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 regulations of the San Joaquin Local Health District. <br /> Home owner or lidensed 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 Califorpla." Contractors hiring or sub-contracting signature <br /> certifies the following: "1 dertify that in the performance of the work for which this permit is issued,hshall employ persons subject to workman's compensa- <br /> tion laws of Cal"rfor a.� <br /> The applicant m [ c Iffor all req ired inspect' ns. Complete drawing on reverse side. `p <br /> Signed X Title: _ Date: <br /> FOR DEPORTMENT USE ONLY O <br /> Application Accepted by Date �" Area <br /> Pit or Grout Inspection by Date Final Inspection by Date : o S <br /> Additional Comments: C1"'I Nut Via av✓ (�lh)1 11--G Grvl�p-cv.b rtJJl�rr-/ C�Ui.H✓ ✓'f �{�-rG L <br /> El Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 8355-6385 -J 4771"5 h 5-C <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT - <br /> NFO CASH <br /> EH 1124 IREV.IVRW <br /> { EH 141E <br />