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i <br /> APPLICATION FOR PERMIT I U,i°ev", <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTW�n� <br /> 1601 E. HAZELTON 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. <br /> Job Address Z Sq 00 E, " °1°" _ City �� Lot Size t PM <br /> Owner's Name __Ll_�{�� r•+G(Y'C@' J -_ Address 2 �[.fT' � 1^�� PS ne <br /> Contractor Address C 90d _ License No. Phone� [ <br /> TYPE OF WELL/PUMP: NEW WELL 1 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ f ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL A-PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑_Open„Bottom ❑.Manteca.- DWell Exca <br /> ia. of vation �..�Dia of Well Casing <br /> *Domestic/Private Gravel Pack ❑ Tracy Type of Casing _ Specifications <br /> ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout -. <br /> I I Irrigation ."Approx. Depth LLI��I_Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump SUIM H.P. 7� State Work Done _Azo l! A,;Al , <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material`(Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is Q <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T e/Mf f <br /> YP 9 Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distafte,to nearest: Well £Foundation Property Line S <br /> SEEPAGE PITS l 1 Depth Size <br /> Number <br /> SUMPS Ll 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: '9 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 to become subject to workman's compensation laws of California Contractors 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 California " <br /> The applicant u call for all requ'r spection omplete clrawi�@ on reverse side. <br /> Signed X <br /> e: � � Date: <br /> 2M_ <br /> DEPARTMENT USE ONLY <br /> Application Accepted b1by <br /> Date Ck l Area d Z 6 <br /> q�,./Pit ov rout I spection Date � Final Inspection by DateAdditional Comments: �{) oT❑ Stk 466-6781 -3621 ❑ Manteca 823- 04 ❑ Tracy 835-6385 <br /> Applicant - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVER BY DATE PER17'N <br /> CK 0 <br /> ♦.EH 13-21(REV.t i H � �++� ��� I <br /> EH 14-20 ,� <br /> VP"t1 Q' <br />