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w <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 Districtt� V Icize s PM <br /> Job Address <br /> ,(,��� N• �� J� +�+�J City O� Lot Size_ - <br /> r� <br /> J <br /> —'�{ ocfs �0�'lJ -�lP - Phone <br /> Owner's Name 1Address C� <br /> l u'/aril A1�1e.�� Phone <br /> <<� .-- <br /> Address /cense No. <br /> Contractus ��-- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial 11-0p. Bottom ❑ Manteca Dia. of Well Excavation <br /> FSpecifications <br /> ❑ Tracy Type of Casing <br /> D Domestic IPrivate ❑ Gravel Pack <br /> Type of Grout <br /> {"1 Public (-I Other Cl Delta Depth of Grout Seal <br /> i _A xox. Depth. I`,.Eastern... _Surface Seal Installed by <br /> I f Irrigation —.Approx. State Work done <br /> Repair Work Done L3 Type of Pump H.P. <br /> Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter ,y <br /> Depth Filler Material fBelo 50'1 J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION i DESTRUCTION I l arvailableseptic <br /> w thin 200 feet.) <br /> if public sewer is yes <br /> Installation will serve: Residence_ Commercial Other - 1 <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK E_ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE �No. & Length of fines <br /> LXX e Total length/size <br /> ❑ Distance to nearest: Well FILTER BER +50 Foundation L� Property Line <br /> J�-- <br /> SEEPAGE PITS I I Depth <br /> Size Number <br /> SUMPS <br /> l_I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <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. <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 /> signature <br /> employ any person in such manner as to become subject to workman's compensation it is ss California." ploy lctosonstring or sub'subject to woorkm n'scompensa- <br /> certifies the following:"I certify that in the performance Of the work for which this permit is issued,i shall employ pe l <br /> tion laws of California." <br /> The applica%.au st-aall for all required ins coons. Complete drawing on reverse side. <br /> IJV+Z �e.il� Title: M0.AeIrLW— Date: <br /> Signed X <br /> �F R DEPARTMENT USE ONLY ;x <br /> ,GfDate 7 Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> C1Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 63$5 <br /> Applicant - Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009r Stk., CA 95201 <br /> ffFE MOUNT DUE AMOUNT REMITr1: RECEIVED BY DATE PERMIT NO. <br /> EM 1]-21lPEV.tiH51 '; �� rr•✓% ,� y <br /> EH 14-26 d J <br />