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t} <br />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 />I Complete in Triplicate) <br />t 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 ismadeincompliancewithSanJoaquinCountyOrdinanceNo. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San JoaquinLocalHealthDistrict. <br />Jab Address S Cr 4ad City Lot Size PM <br />Owner's Name Address R 1PQ 4 A5 I Phone <br />Contractor's Name License No. Phone T <br />TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION Q <br />PUMP INSTALLATION SYSTEM REPAIR OTHER <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 <br />Industrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well CasingDomestic/Private Gravel Pack Tracy Type of Casing SpecificationsPublicOtherDeltaDepthofGroutSealTypeofGroutIrrigationApprox. Depth Eastern Surface Seal Installed by WRepairWorkDone ^ Type of Pump H.P. State Work bone <br />Well Destruction El Well Diameter Seating Material ftop 50'} <br />Depth Filler Material {Below 501) <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sewer is <br />available within 200 feet.)Installation will serve: .Residence Commercial_ Other <br />Number of living units: Number of bedrooms yF 0Characterofsoiltoadepthof3feet: <br />Water table depth V iSEPTICTANKType/Mfg' 1CapacityNo. CompartmentsPKG. TREATMENT PLT. t <br />Method of Disposal I <br />Distance to nearest: UVeI! Foundation Property Line <br />t <br />LEACHING LINE q No. & Length of,lines 146 Tolallength/size <br />FILTER BED <br />l <br />i <br />11 <br />Distance to nearest: Well i}= Foundation Property Line <br />SEEPAGE PITS ' Depth <br />7. <br />Size Number <br />iSUMPSw,Distance to nearest: Well 1(10 Foundation—22 Property Line I <br />DISPOSAL PONDS <br />i <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,rules and regulations of the San Joaquin Local Health District. state laws, and <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 notemployanypersoninsuchmannerastobecomesubjecttoworkman's compensation laws of California."Contractor's hiring or sub-contracting signaturecertifiesthefollowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-tion laws of California." <br />The applicant must`ll for all repyjied inspections. Complete drawing on reverse sides-• - w <br />Signed <br />1J <br />Title:, f Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by x <br />aa-L— Date Area 6 <br />Pit or Grout Inspection by' Date Final Inspection by Date -f <br />Additional Comments: <br />Stk 466-6781 Lodi 369-3621 CI Manteca 823-7104 Tracy 835-6385 <br />Applicant- Return all copies to: Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Ir <br />FEE gMOUNT DUE AMOUNT REMITTEDINFO <br />CK <br />RECEIVED BY DATE PERMIT'NO. <br />EH 13-24(REV,101e31 <br />EH 1426