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APPLICATION FOR PERMIT 6A/ SA;r" �+ <br /> ' d SAKI JOAQUIN LOCAL HEALTH DISTRICT ijj{a <br /> ? 1601 E. HAZELTON AVE., STOCKTON, CA �LD� � <br /> Telephone 12091 466-6781 ?-Oct` 4f 30-0 r <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> fat is <br /> irx Cauo Ordinance No.549 for sewage or No. 1!362 for well/ and thefk <br /> R���444IIIulati f a Joaquin <br /> Application is hereby made to th9 San Joaquin Local Health District for a permit to construct and/or instalk the eincri <br /> made in compliance with.San-io�qu tY <br /> Local Health Dist(! I/ <br /> Lot Size /�a /�C <br /> City . PM <br /> Job Addres ��� <br /> Address Phone <br /> Owner's Name �Ja^ <br /> 29 !E F*L j..0 License No,5512;tfiLS Phone <br /> Contractor Address ' <br /> TYPE OF WELL/PUMP: -'1, NEW WELL ❑ WELL REPLACEMENT d DESTRUCTION © / (,•1A , <br /> SYSTEM REPAIR 0 OTHER <br /> PUMP INSTALLATION ❑ 4 <br /> i •� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑Industrial 0 Open Bottom 1-7 Manteca Dia. of Well Excavation Specifications <br /> LJ Domestic/Private g( ❑ Gravel Pack C3 Tracy Type of Casing Type of Grout <br /> I'1 Public �J� n r01", / Cl Delta Depth of Grout eal u „Y <br /> �ZA rox. Depth l•1 Eastern Surface Seal Ins ailed <br /> by <br /> I i Irrigation pp H P State Work Done <br /> Repair Work Done IJ Type of Pump /;st31►IiJ�S �Hf� -(Q <br /> Well Destruction ❑ Well Diameter Sealing Material I=5011 _ ASS1Z&f19C.- <br /> f Depth_ Filler,Material (Below 50' <br /> TYPE OF SW <br /> EPTIC ORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DES RUCTION t I INo availa lelwithin?2MJe tsystem ttes� d if public r is <br /> 9.1A <br /> Installation will serve: Residence— ComrrteMiai_ Other <br /> Number of living units: ^ Number of bedrooms ept <br /> Character of soil to a depth,bi 3 toot: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑= Type/Mfg - <br /> PKG. TREATMENT PLT. ❑ �, Method of Disposal <br /> Distance to nearest: Well <br /> Foundation ,Property Line <br /> 4 <br /> ' Total Length/size <br /> LEACHING LINE Cl No. &Length of lines <br /> FILTER BED .❑ :Distance to nearest: Well Foundation Property Line <br /> E <br /> SEEPAGE PITS ( I Depth Size Number - <br /> SUMPS L I (Distance to nearest•. Well Foundation Property Line <br /> piSPOSAL PONDS ❑ .4 <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 D3trict. <br /> i <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 /> I <br /> any person in such manner as to become subject to workman's compensation laws of California."Cantractafs hiring or sub contracting signature _ <br /> certifies the following:"I certify that" the performance of the work for which this permit is issued,I shall employ persons subject to workman's cortpensa- <br /> tion laws of Cafifor it <br /> The applicant i e 'ons. Complete drawing o averse side. ,� Date: <br /> Signed <br /> �7 <br /> Signed Title: [ <br /> i <br /> OR DEPARTMENT USE ONLY <br /> # Date Area <br /> Application Accepted by. <br /> t 7 <br /> Pit or Grout Inspection by <br /> Data Final Inspection by Date <br /> w <br /> Additional Comments: <br /> O Stk 466-6791 ❑ Lodi 389-3621 0 Ma ace 823-7104 ❑Tracy !335-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> k nEE AM<�UNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PEAMIT'NO. <br /> ENl121iRtv.1A51 'I �4ca <br /> j EH 142E <br /> 6 II <br /> r . <br /> i <br />