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r r h <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 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 describ d. 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 Regulatio s of the San Joaquin <br /> Local Health District. <br /> Job Address 7 (' C LA, — S cl A L C City C A Loi Size <br /> PM <br /> Owner's Name L �J Ll~ Address 7!o Cl A4 jL,S L �Phr nem. n <br /> I 'E L`I`B} PU C v > <br /> Contractor LAddress � ��� � S?`1� License No Phone Phgne <br /> TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM R5PAIR ❑ OTHER <br /> I DISTANCE TO NEARES.J._SEPTIC TANK' g� SEWER LINES r <br /> DISPOSAL FLD.`^ ROP. LINE SLC <br /> FOUNDATION ZQAGRICULTURE WELL f Oa OTHER WELL Cv t9 <br /> ITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS / r <br /> Cl Industrial © Open Bottom ❑ Manteca Dia" of Well Excavatianl� Dia of Well Casing. (o <br /> i CK Domestic/Private Q<Gravel Pack ❑ Tracy Type of Casing Sp cifications <br /> �M Public F1 Other fl Delta _ Depth of Grout Seal cA (D6 <br /> Ty of Grout *y z <br /> I I Irrigation —.Approx..De h i I Eastern Surface Seal Installed by " E: <br /> Repair Work Done f3 Type of Pump " H.P. _ - State Work Done_ �T <br /> f <br /> Wel! Destruction ❑ Wel! Diameter Sealing Material (tap 50'1 <br /> Depth Filler Material (Below 50') I c is 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIRIADDITION i 1 DESTRUCTION I I (No septic-system permitted!if public sewer is <br /> available within 200 feet.) <br /> ;�ranstallation.will serve-..M Residence— Commercial Other i <br /> w .- - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: — Water table depth ! x <br /> SEPTIC TANK ❑ Type/Mfg- ` Ca Capacity_ 1 <br /> _ p Y i No. Cofnpart nts <br /> PKG. TREATMENT PLT. ❑ ­' ��INethod of Di sposal 4 <br /> Distance to nearest: Well •-;-----Foundation <br /> Prop�ity.Line " <br /> LEACHING LINE Cl No. & Length of linesLi <br /> Total length/sig z W <br /> FILTER BED ❑ Distance to nearest: <br /> Well Foundation Property Line <br /> Y- <br /> SEEPAGE PITS I I Depth Size <br /> Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property <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 co mand--* <br /> ordinances, state,laws, an <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 whic thl's� ; <br /> em permit is issued, I shall not <br /> to ) <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hi ing 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 personssubject to workman's compensa- <br /> tion taws of California." <br /> The applicant m call for all re u, d inspection's.'Complete drawing o averse side. <br /> Signed X Dte: 777 6 cY-Z <br /> FO FDEPARTMENT USE ONLY <br /> Applicatio Accepted by Date Area <br /> t <br /> € Pit or ro Inspection by te, ' Final Inspection by " Dates <br /> ' Additional Comments: 'L <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca -7104ii;Tracy 835 6385 <br /> Applicant Return all copies Environmental Health Per it/Se ices 1 1; - azalton A e., P.O. Box 2009; tk, <br /> FEEAMOUNT'DUET AMOUNT REMITTED CK v <br /> INFO CASH RECEIVED By. E PERMIT'NO. l <br /> wAl <br /> t� S /// <br /> +.EH1 <br /> 3-24 4FIEV")i H 5) <br /> EH 14-29 <br />