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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4•YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t <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 i <br /> Local Health District. <br /> I PM <br /> Job Address 12120 ,-. <br /> 1lThhariCl RCI_ City Lot Size <br /> Owner's Name Mi ch ipl Rodgers <br /> Address 12420 N. Hihb.arr fid, Phone <br /> 17754 N. Hwy. 88 ' <br /> Contractor <br /> Address l�-CISP �L^f C A 1 i f_ i Z License No._3D9D3L—Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP INSTALLATION)CK "" SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> IN NDED USE TYPE OF WELL PROFILE A'flEA CONSTftOCTION-SPECiFICATIOt S <br /> El Industrial "' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> [I Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing specifications <br /> f'l Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> { I Irrigation _Approx#Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump Slth_ H.P- I state Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50T <br /> Depth i Filler Material (Below 501 - —w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTION I I iNo septic system permitted if public sewer is �] <br /> i available within,2T feW'i "I 1_ <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water tablede,th <br /> SEPTIC TANK ElType/Mfg Capacity <br /> No. Co pa�rrYents <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property<Lirie � 'w'=idit.,l•,� r+'' ' <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Tata) length/size <br /> FILTER BED [I Distance to nearest: Well'l Foundation Property Line <br /> SEEPAGE PITS I ) Depth Size —t _ Number <br /> SUMPS -❑—Distance"to nearest: -Well ' - Foundation Property Line <br /> DISPOSAL PONDS ❑ r.- - <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 ignature 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#' . <br /> er as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followithat 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 CalifoThe applicant mus r uired inspections. Complete drawing on reverse side. <br /> signed Title: Rkpr Date: <br /> OR DEP HENT USE ONLY <br /> '1 L <br /> Application Accepted by s Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> f <br /> I Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> AMOUNT Dt AMOUNT REMITTED CIC RECEIVED BY DATE PERMIT NO. <br /> ' FEE CASH <br /> INFO ^� ' <br /> EH 13-241REV.�/H5Y �! ( <br /> EH 14-28 <br />