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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE,, STOCKTON, CA <br /> Telephone (209) 466-6781 <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. <br /> F' Job Address �l0�! k1 A-tFAZ e'/% City o Lot Size /i/.Gd c'2eSPM <br /> Owner's Name Address /b�/$" CrPeSf1I i uJ A�. Phone '95/01/ <br /> {� <br /> r � <br /> Contractor Address License No. Phone O <br /> TYPE OF WELL/PUMPV NEW WELL Vt WELL REPLACEMENT ❑ DESTRUCTION ❑ o , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />( INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />{ ❑ Public ❑ Other— �" ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation -L—Approx. Depth © Eastern Surface Seal Installed by <br /> F 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 /> r - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic 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 bedrooms -3 <br /> i <br /> Character of soil to a depth of 3 feet: 5-4110d-- y Water table depth �-� <br /> . L <br /> SEPTIC TANK tr21'� Type/Mfg Capacity 1,100 No. Compartments <br /> 1 PKG. TREATMENT PLT. ❑ 1 :­� "+ / � Method of Disposal <br /> r Distance to nearest:. well 'fib Foundation Property Line <br /> I LEACHING LINE ❑{No. & Length of lines (>a �,7otal length/size---d-149. <br />` FILTER BED ❑ Distance to nearest: Well__A0__0,-`Foundation Property Line .5— <br /> I SEEPAGE PITS L] s Depth' Size Number <br /> 4 SUMPS El';Distance'o nearest: Well Foundation .A 'Property Line <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 regulations of the San Joaquin Local Health District. w <br /> Home owner or licensed 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 California."Contractor's-hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant crust call for Il required inspections. Complete drawing on reverse side. <br /> 4 � £ <br /> Signed X Title: cu-37 er- Date: 24,x? <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted Date `oVG-7 Area <br /> Pit or Grout Inspection by -f Date Final Inspection by 2J Date — 7 <br /> Additional Comments: y <br /> ❑ Stk 466-6781 ❑ Lodi 3(9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> + EH 14-241REV.I/85) J • ` O / <br /> k FH 14-28 f <br />