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APPLICATION FOR PERMIT /Woo, ,...; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I 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 San Joaquin <br /> Local Health District. �'j t j D <br /> Job Address ,`�� rAEo� " AU 1 f C- Lot Size �7"' �j PM i <br /> Owner's Name .- Address , Phone <br /> f Contractor4wo Address.■ r� ZER <br /> License Np �T Phone/�� `��� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ) <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j 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 Ezcavati6ri Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ TraVy,-, s Type of Casing_ a Specifications <br /> ❑ Public ❑ Other ❑ Deita s k "-''Depth of Grout;Seaa ` 'S` Type of iGrout <br /> ❑ Irrigatibn --Approx. Depth ❑ Easterner Surface Seal Installed by <br /> Repair Work.Done ❑ Type of Pump H.P. 2 _-._»- :r- - State Work Done <br /> Well Destruction ❑ Well Diameter 'i, Z ,, Sealing Material (top 501 <br /> Depth t, Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ,available within 200 feet.) ;} <br /> r <br /> t Installation,will serve: Residence Commercial Other .� <br /> y Number ofliving units: Number of drooms Z "` <br /> :r <br /> Character 651'soil to a depth of 3 feet: '''� Water table depth .f <br /> SEPTIC TANkF ❑ Type/Mfg ' Capacity No. Compartments, <br /> PKG. TREATMENT PLT. ❑ /D Method of Disp�, ! <br /> Distance to nearest: well Foundation Property Line /0 !l <br /> LEACHING L(NE No. & Length of lines i `" Total length/size X, Ih <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line OV <br /> �— <br /> f <br /> SEEPAGE PITS Depth �S Size _3,6 Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line '! <br /> ! DISPOSALPONDS ❑ <br /> ws <br /> , and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner br licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I`sh <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 laall not <br /> employ any person in such manner as to become subject 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 of Cal"ornia." :i <br /> The applica m c or all ui ins c'ons. Complete drawing on reversoide. <br /> SignedTitle: _ Date: !;:0-13 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~� Area <br /> Pit r Grout Inspection byate�iD�Q Final Inspection by Date7-21119 <br /> Additional Comments: <br /> ❑ Stk 4WO,81 ❑ Lodi 369-3621 - ❑ Manteca 823-7104' ❑ Tracy 6354MM II <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t w � •l <br /> t <br /> I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> {INFO CASH / J <br /> + EH 13-24 <br /> EH 1425(REV.1/a5) Oo <br /> ti <br />