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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON', CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> ' City J/ � Lot Size Address C A6WAx PM <br /> Owner's Name _�7 /y1�T,�' - /J�L170/(��ddress /+J�S Jy Phone --- <br /> t t♦iEl/gp`�/�. <br /> Contractor Address r, / lkl/L�'e!L ,[ET2,L,Icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELLJW t WELL REPLACEMENT ❑ DESTRUCTION 0 Ita <br /> PUMP INSTFILL4TIOfV—;1�%""'""""' 'SYSTEM-REP;41R"'�7-"°�- � 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 f CONSTRUCTION SPECIFICATIONS T ' <br /> 4 El Industrial ❑ Open Bottom — ❑ Manteca. 'r,Dia. of Well Excavation 1Z -Dia.'of.Well Casing <br /> © Domestic/Private ❑ Gravel Pack'';_4 ❑ Tracy--_i• t ,Type of Casing Specifications <br /> )Public 11 Other 11 Delta "J 4 Depth of Giout Seal �d t Type of Grout.'= F_)lUl <br /> 1 1 Irrigation Z&._Approx. Depth t I Eastem ` Surf a Seal Installed by <br /> Repair Work Done ❑ Type of Pump , H ~ State Work Done= '[ <br /> Well Destruction ❑ Well.Diameter Sealing Material Itop 50') ! �J <br /> DePO Filler Material (Below°501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION [ I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> tion will serve: Residence_ Commercial Othef : <br /> Number of by its: Number of be <br /> Yom. " - - - -- "" , <br /> Character of soil to a de' ' feet: ""' F �, ,,._�_«» Water tableifepth <br /> SEPTIC TANK ❑ Type/Mfg ~� -t Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ) Cie <br /> Method of Disposal llaa <br /> Distance to nearest: ° -Well oundation *- Property Line �. <br /> LEACHING LINE 0 No. & Length-of lines ength/size <br /> FILTER BED ❑ Distance•to nearest: __Well. Foundation .Prop eine.- <br /> SEEPAGE PITS l I Depth Size Number ' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS- ❑ <br /> 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 Di§trict. <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 to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> i 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 IE or all re uired inspections. Complete drawing on revers side. <br /> Signed X Title: Date: S D0 <br /> R DEPARTMENT USE ONLY <br /> " Application Accepted by Date // Area <br /> Pit or Grout Inspection by ' Date Fi al Inspection by /n' Date <br /> i � w <br /> Additional Comments: L� <br /> ❑ Stk 466-6781 C3 Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 W <br /> Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 4 <br /> CK 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> } +.EH13-24IREV.t/AsfX79 <br /> t EH 14,28 <br />