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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> j Telephone (209) 466-6781 �, �p "t,-rt. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> , <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 /> Ordinance No.649 for sewage or No. 1882 for well/pump and the Rules and Regulationti of the San Joaquin <br /> made in compliance with Sen Joaquin County <br /> tr. ..�..:, . <br /> Local Health District.,. . ;' /Uy RV ;!NO <br /> Job Address - - City.fay- `ot Sae - .PM <br /> ����,(�A ` `2 33 -S N f- -Q M 6 4: ,. <br /> owners Nemo�YJ1 '" y «' 12 =""stem <br /> Contractors Name ' icense No. Pho ' <br /> PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLP,LTION ❑ SYSTEM REPAIR C1OTHER 13 <br /> !k\� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK�^' SEWER LINES <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> \, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a <br /> ❑ Indusoial ❑ Open Bottom nDia. 01 Well Casing. <br /> ❑-Meteca� 6ie�bt.weil'Fxcavation <br /> Tof Cesi Specifications r <br /> ❑ Domeedc/Private ❑ Gravel Pack `I C Tracy T of Grout <br /> C Public C Other. , A"r-` ❑❑ Delta, Depth\of Grout Seal YPa ` _ ty <br /> C Irrigation �pprox. 1 ❑ Eastern Su m-Seel Installed by <br /> Repair Work Done ❑ Type of Pump -'°'- H.P. - State Work Done ' <br /> Well Destruction C Well D-iameter3., Sealing Materiel ltop 80') <br /> Deter Filler Material IBeIoW 88'1 l <br /> TYPE OF SEPTIC WORK: NEW INSTALLA�ON C REPAIR/ADDITION C `DESTRUCTION C awoila septic sys 8200In enn d pubik sewer is Z ` <br /> i <br /> fee <br /> Installation will serve: Residence__ Cofnmercial,—_Other r <br /> Number of living units: —(Number OJ.bodmoms <br /> Character of soll to a depth of 3 feat: `t"'� � 'Zay�� Water table depth 2_' n <br /> i Capacity_�E ,¢rtr�No. Compartments ' T <br /> SEPTIC TANK O_'TvPe/Mfg <br /> Capacity_,Aa �v n <br /> PKG. TREATMENT PLT. ❑ ' i y Method of Disposal <br /> Dista e4 to rat:� Web"'� G Foundation Property Line 00 <br /> . . <br /> LEACHING LINE H No. 6 Length of linea —, \� fTo I length/sae , <br /> FILTER BED ®6istahce to nearest: Well, Founda0- -?��r ' Property Line <br /> I 1: <br /> SEEPAGE PITS ,Depth _.�� -Sae—,��.�F,�� Number <br /> SUMPS ❑ Distance to(nearest: 'Well/ Foundation / Property Litre <br /> DISPOSAL PONDS 11 <br /> I hereby certify that I have prepared this application and that the Work will be done in accordance with San Joaquin county ordinances,auto laws,and <br /> rules and regulations of the San Joaquln Local Health District. j <br /> Home owner or licensed agent's signature certifles the following: "I certify that in the performance of the Work for Which this permit IS issued, I shall not <br /> empioy any person in such manner as to become wbiect to workman's compensation laws of California."Contractors hiring or sub-centractirp signature <br /> certifies the following: "I certify that in the perforance of the wP6790110oork for which this permit is Issued,I shall employ persowbi0ct tWorkmen's compensa- <br /> mi <br /> tion laws of Califomia." /pq <br /> The applicant upi s1 cell for i re9uired inspecd'n . Complete drawing on reverse aide.. ' p <br /> . <br /> Signed X /Jr•�A , Title: ., f Lots Data•/ _ FO DEPARTMENT USE ONY/1.,yy11� IAtn t`� ` a = .S Data .Application Accepred by, U� - — ur <br /> I . <br /> e <br /> XT <br /> Grout Inspection by WeLO i -S-rFinsl Inspection by Dtla �r <br /> Additional Comments: <br /> ❑ Stk 4666781 ❑ Lodi 31119-3821 ❑ Manteca 827.7104 ❑Tracy. <br /> Applicant- Return all copies to: Environ;ntd Health Permit/Services 1601 E. Hes lion Aw., P.O. Box 2009, StI CA 58201 <br /> FEE AM I If,I DUE 1 AMOUNT REMI TEO CABN RECENED BY DATF PERMn"NO. � <br /> INFO �i <br /> ER 11]/(REV.lel®1 1 <br /> EH 141a <br />