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Zf 0 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 District. ,. ��/q' ` <br /> Job Address I / -7 " " �+�-v�/�'e City-IL& Lot Size PM <br /> Owner's Name ^Address 1 t Phone Q <br /> Contractor Address U�.SIO G"%� 4.yYt.¢2> License No.YD PhoneT 7 0-J"-/G.:it <br /> TYPE OF WELL/PUMP:e NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t} <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { <br /> 0 Industrial ? ❑ Open Bottom ❑ Manteca _ Dia. of Well Excavation Dia. Idf Well Casing ) <br /> 0 bomestic/Private ❑Gravel Pack tt ❑ Tracy -Type of Casing Specifications I <br /> f;l_Public ❑ other { ❑ Delta Depth of Grout Seal Type of Grout <br /> A I I irrigation ( —Approx. Depth III I I Eastern Surface Saul Installed by <br /> Repair Work Done ❑ Type of Pump ( H.Pt State Work Done <br /> + � Well Destruction ❑ -Well Diameter?, ) Sealing Material (top 509 ~ ` <br /> 4 Depth i Fillerfrvlaterial (Below 509 <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I 1 Min septic system 'Permitted if public sewer is ( 1 <br /> available within 20 set.) I <br /> Installation will serve: Residence— Comments r <br /> Ot \ - <br /> Number of living units: _ Number of betlroo <br /> Oharacter dlspil-madeptho1-3 feet:-'— °r r ����A Water table depth <br /> SEPTIC TANK O Type/Mfg ' Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑'+:; �'.sfy t Method of Disposal <br /> tr <br /> Distance tonearest: ,'Well Foundation Property Line <br /> t" _ <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑ Distance [o flearest:- Well' - t' Foundation Property Lim1 <br /> !PSAL'PONDS <br /> ITS 11 Depth Size Y..*:� Numbe U A4 <br /> 0 Distance tone est: allProperty Line❑ <br /> hereby certify that I have prepared this application d that the work will(be o e in accordance with San Joaquin county ordinances, state laws, and/ <br /> -rules and regulations of.the San Joaquin Local Healt 13trict. l <br /> Home owner or licensed agent's signature certifies the mg: " 1 Y 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 we man's conjpensation laws of California.";Contractors hiring or subcontracting 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." J <br /> Thei applicant wet call for quirad in sctions. Complete drawing.dnpveraLa side. 1 <br /> Sig,lled X W-111 Title: ? /1.�%'KYL�' Date: 11 <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by f � Data � Area <br /> Pit or Grout Inspection by Date Final Inspection by Data S-- <br /> AddAll� <br /> Additional Comments: - <br /> 0 9tk 466-6781 ❑ Lodi 369- C-Manteca 1123-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services, 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> � s ( <br /> I INFO AMOUNT DUE AMOUNT REA(ITTE0 CASH RECEIVED BY DATE PERMIT'NO. <br /> I r�: <br /> +.EN 1324(REV.I1951 ��-�,^ .� Slit i r� '�aa,..., <br />