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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k ' <br /> 1601 ,E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED r <br /> r <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 /> j 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. <br /> / J�/ cai 'v fir/ t i " <br /> Job Address ! !• ,_.._ � Cit �/.GT� Lot Size G PM <br /> Y �,. <br /> Owner's Name � Ilrt! A �a z i Address /«/ iA10S'� 1 'f Phone 6,%47P <br /> Contractor "`y� _Address License r4o. Phone <br /> TYPE OF_WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION ID <br /> PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ �= -;"OTHER-© ---.-- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 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 Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> M Public k7 Other Cl Delta Depth of Grout Sea] Type of Grout ~" <br /> I I Irrigation• Approx. Depth I.I Eastern Surface Seal Installed by _ <br /> ."'Repair Work Dane ❑ `Type of Pump H.P. State Work Done_ <br /> Well Destruction © Well Diameter Sealing Material (top 501 <br /> Depth if <br /> Filler Materia! (Below 50'1 <br /> ' 'TYPE OF SEPTIC WORK: NEW INSTALLATION l'I REPAIR/ADDITIONfii- DESTRUCTION I I (No septic system permittedif public sewer is <br /> t avaikable within 200 feet.) <br /> Installation will serve: Residence Commercial— Other ' <br /> I <br /> Number of living units: Z Number of bedrooms --? <br /> Character of soil to a depth of 3 feet _ ( ?'.> ' Water table depth- <br /> SEPTIC TANK ❑ Type/Mfg 10 J. Capacity 14,120r4 d,- No. Compartments t <br /> PKG. TREATMENT PLT. CIMethod of Disposal <br /> �"' ►- Distance to nearest: Well I-PI J Foundation Property line //�Z 7 <br /> r LEACHING LINE ❑ No. & Length of lines fr Taal length/size <br /> FILTER BED ❑ Distance to.nearest: Well ��` Foundation ��"�- Property Eine <br /> SEEPAGE PITS ('I. Depth } Size Number 7771 <br /> -SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. 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 /> employ any person in such manner as t6becomesubject to workman's-compensation laws of California." Contractor's hiring or sub-contracting 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.ofXCalifornia." .x w r{ Icy,�.•- .. ' ?r <br /> The applicant must call for'all retired inspections.-Complete-drawing on reverse side. 5 <br /> : Signed X . .•- 6�'• [ r. j Title: Jf r F d / :-. 1 f f 4� <br /> - Date: <br /> Y FO DEPA ENT USE ONLY <br /> Application Accepted by Date i`.- �Aea <br /> Pit or Grout Inspection by '~ Date Final Inspection by Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621--. .0-Manteca 7104 ❑ Tracy 835-6385 ` <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton_Ave.,-P:O:Boz 2009, Stl , CA 95201 <br /> INFO YOUNT DUE; AM UNT REMITTED CK RECEYJD BY DATE PERMIT'NO. <br /> +.EH1 <br /> 3-241REV.iiws5 La boo <br />