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} <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 TY•,EAR FROM DATE ISSUED <br /> (Complete 46 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �s� PO*!. '-j; P� City Lot Size . ,_• _ _ PM <br /> Owner's Name G�(44,k �_�_ Address',`.," Phone <br /> Contractor —Address" b <br /> y License No.4 Phone <br /> TYPE OF WELL/PUMP: NEW'WELL-.L7. a, 1�WELL,REPLACEMENT ❑A o DESTRUCTION D <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ """"q'OTHER ❑-- +►- r <br /> DISTANCE JO-N EAR EST: SEPTIC.TANK I <br /> _ $E1NER,LINE5 fi DISPOSAL FLD. PROP. LINE <br /> n FOUNDATION '4* y AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> f <br /> ff <br /> INTENDED USE TYPE OF <br /> ". ELl�PRQBLEM AREA ONSTRUCTION SPECIFICATIONS <br /> 13 Industrial ❑ OpentBo mx.y ❑ManfesdDia. of Well Excavation Dia.of Well Casing <br /> t ❑ Domestic/Private ❑ GravelPace- ra x,� Type of Casing Specifications <br /> 1-1 Public r f 1 Others . " a <br /> Depth of Grout Seal + T <br /> ype of Grout <br /> 1 I Irrigation --Approx. DepthISurface Seal-Installed by f 1 <br /> Repair Work Done ❑ <br /> Type of Pum ' - 1 <br /> yp p I H-P State Work Done_ ■ <br /> Well Destruction, C3 Well Diameter Seafing Material (top 501 <br /> S <br /> Depth . 1-Filler-Material-IBelow-50x1 -- --->w4 <br /> {' TYPE.OF SEPTIC WORK: NEW INSTALLATION l.1 REPAIR/ADDITION DESTRUCTION l I INo septic system permitted if public sewer is i <br /> x " �avaiiable within-200-feet.) <br /> r Installation will serve: Residence 'e Commercial— Other I <br /> Number of living units: Number of,be_drooms _ <br /> Charactdr of soil to a depth of 3 fist: -Vt Water table depth j <br /> SEPTIC�TANKType%Mfg w. ` L <br /> Capacity14=00 _ No. Compartments I <br /> PKG. TREATMENT PLT. ❑ <br /> f `i Method of Disposal i <br /> Distance to nearest: Well ._ Foundation_ Property.Line ,__ <br /> LEACHING LINE <br /> No. & Length of linesTotal length/size E <br /> FILTER BED ❑ Distance to nearest:"'—WellQ_ <br /> ° Property <br /> I <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll 5 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. <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 /> "F employ any person in such manner as to becorna'*bject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the a 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." e a <br /> The applicant must call for all re ireinspections. Complete drawing on reverse side. r <br /> Signed X " ` Title: ; <br /> t Date: r L p� <br /> 1 F, R DEPARTMENT USE ONLY � <br /> Application Accepted by "r <br /> "/ ��"" Date YrYX Area �� t <br /> Pitlor Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1� i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO Q C SH RECEIVED BY ,DATE PERMIT NO. <br /> +.EH 14-2g IAEV.r i n 51 ! Q• �-�✓ C !/ Z � > � <br />