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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " 1601 E. HAZEL T ON 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 Sart Joaquin <br /> Local Health District. <br /> ii t r 4 3. j4 <br /> Job Address � .. <br /> City t'ot Si eM <br /> Owner's-Name Address L~ - Phone <br /> 'a_ v Yom— .yam- <br /> j ContractorsLF Address �a> License No <br /> s+ Phoneq <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION El <br /> r PUMP INSTALLATION Ll _ Y� SYSTEM REPAIR ElOTHER ❑ r s <br /> DISTANCE TO NEAREST: SEPTIC TANK~ SEWER LINES =` "" DISPOSAL FLD- ' PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE • TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-,` s <br /> ❑ d I <br /> El Open Bottom �l Manteca•:- Dia. of Well Excavation Dia of-�/Vell Casing I <br /> Type of Casing Specifications 4 <br /> ❑ Domestic/Private I Pack f❑ Tracy YP i . q i <br /> Depth of Grout Seal Type of Grout <br /> ❑ Pubrlic ❑ Other 4 ¢^ t h I <br /> ❑ Irrigation --Approx. Depth 11Eastern Installed'by _ r ` <br /> Repair,Work Done 0 Type of Pump `` H P• a ne.T <br /> WeIliDestruction ❑ Well Oiameter pSealing Material (top 50'1 <br /> Depth Filler Material (Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR,/ADDITION ElDESTRUCTION LJ (No septic system permitted if public sewer is <br /> k g available within 200 feet.) <br /> :. Installation will serve: Residence Commercial'l€r`-1 Other <br /> f <br /> Number of living units: Number of bedrooms. -{ <br /> Character of soil to a depth of 3 feet �--x-{ Wil ta¢Ig depth _.._ <br /> SEPTIC TANK ❑ Type/Mfg " Capacity r No. Compartments t <br /> PKG. TREATMENT PLT- El {* - -»�-��-;'" (Method Qisp al <br /> 4 �^/ <br /> Distance�to-nearest: s Well Foundation IOL L Property line j <br /> c• ` Total length/size I <br /> LEACHING LINE ' No. & Lengtf.of lines �V <br /> r { Foundation Property Line <br /> a FILTER BED ; ❑ Distance'to;nearest: Well�,S <br /> t <br /> SEEPAGE PITS ❑` Depth Size 13 Number <br /> ❑ Distance to nearest: Well /06 _— Found tion 41047 ?"roperty Line <br /> DISPOSAL PONDS r. Q <br /> e 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 /> x rules and regulations of the San Joaquin Loco Health.District. E <br /> Home owner or licensed agent's signature certifies theJollowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not t <br /> H,-me <br /> any person in such manner as to become,suN t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> I 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." "/,.. <br /> = s <br /> The applican ust call fo all requ'ed in�5pections:Complete drawing on revere side. <br /> �^ <br /> F <br /> Date: <br /> Signed X � �"'�� � Title: ia.�lA �. <br /> 1 r <br /> T USE ONLY <br /> EPARTMEN . .I <br /> Application- ccepted b Date Area 1 / <br /> f v <br /> s Pit or Grout Inspecti Date :Final Inspection by Date��P <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca. 823-7104 ❑ Tracy 835-6385 f <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �r W. <br /> dCK 40 <br /> # FEE AMOUNT DUE - AMOUNT REMITTED ASH RECEIVED BY- -DATE PERMIT NO. <br /> INFO l <br /> 1428 O r _ / +O <br />