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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> r 1601 E. HAZELTON AVE„ STOCKTON, CA <br /> Telephone {248) 466-87$1 PERMIT EXPIRES TYEAR FROM DATE ISSUED SCONED <br /> I(Complate in Triplicate) <br /> Application is hereby made to the San Joaouin Local Health District for a permit 10 construct and/or install the work herein described. This 8pPlication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1062 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address G2,0 We1� C'� � W Cily SiGL�ro", Lot Sire PM <br /> Owner's Name J�t4t\ of 1 Address ?C�. Sac�,r�v�tl.-. { COY Phone 9l61' 161-0'A0Q <br /> S serve 11�,,, y C <br /> . -1932 oc1u 11, ly 1511(31-1 l,09/575-257 <br /> Contractor AddressF� License Na.^, Phone <br /> TYPE OF WELL/PUMP.: NEW WELL 0 WELL REPLACEMENT CJ DESTRUCTION Li <br /> PUMP INSTALLATION n SYSTEM REPAIR C OTHERX':)dJ(- UlRING% ONLY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,_ PROP, LINE <br /> FOUNDATION AGRICULTURE WELL L LL OTHER WELL PITS/SUMPS <br /> -�.._ _ _ <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -N/ Sob;L, &Tz.%46� dor <br /> C Industrial 0 Open Bottom i.1 Mentdca Dia. of Well Excavation Dia. of Welt Casing <br /> F1 Domestic/Private L") Gravel Pack 1-1 Tracy Type of Casing Specifications <br /> I'I Public 1.7 Other I 1 Doha 000111 of Grnut Seal - Type of Grout <br /> I i irrigation ..--.Approx. Depth I i Eastern Surface Semi Installed by <br /> Repair Work Done Ll Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Scaling Material {tap S0') <br /> Depth b— Fillei Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I Ii PAIRIADDITtON I I DESTRUCTION i I (No septic system permitted if public sower is r <br /> available within 200 feet,I <br /> Installation will serve: Residence_ Commercial__ Other <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feat: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation._ Property Line <br /> 9/ALEACHING LINE n No. & Length-of 6n is Total length/size <br /> - FILTER BED 0 distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PETS I I Depth _.. Sire ��.. _ __. r Number ` <br /> SUMPS LI Distance to nearest: Weil _ , . Foundation __ progeny Line <br /> DISPOSAL PONDS L <br /> I hereby certify that I have prepared this application and that the work will I.>Q done in accordance with San Joaquin county ordinances, stale laws, and <br /> I rutes and regulations of the San Joaquin Local Health Diltrict. <br /> t Home owner or licensed agent's signature certifies tilt following: "I certify that in the perlormance Of the work for which this permit is issued, 1 shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following."I certify that in the performance of the work for which this permit is issuers, I shall employ persons subiM to workman's compansa• <br /> Ction laws of California." <br /> r The applicant at call for I equired inspections. Complete drawing on reverse side. <br /> Signed -_- Title:�(,V-'YLR-J1hf ate: <br /> FOR b P l <br /> E ARTMENT USE ONLY <br /> Application Accepted by _. . Date ` ( Area <br /> Pit or Grout Inspection by Dat" Final Inspection by <br /> Date <br /> Additional Comenents: mss, <br /> 0 Stk 488-5781 O Lodi 36S-3Q1 Manteca -7104 l� Tray 835 B3g5 �1e� ;r, ,�� yy <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Ha:alton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> FEt <br /> INFO AMOUNT DUE AMQUNT R[MITTEQ a@CEIVfD pV bail PERMrF NQ. <br /> 3 <br /> •.Eli 13.21 MEV,1 J <br /> :. <br /> IN U-26 �1 < <br />