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aP�Hs APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 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. C) d X 3 G a <br /> Job Address 7 City Lot Size <br /> Owner's Name r v6� dream L Phone <br /> Contractor L�� l �-[� Address S '50ansa Nv-4 :Phone_ -56 <br /> TYPE OF WELL/PUMP: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ff OTHER ❑ a <br /> DISTANCE TO NEAREST: SEPTIC TANK r H SEWER LINES DISPOSAL`FLD. ? PROP. LINE <br /> FOUNDATION" AGRICULTURE WELL OTHER WA=LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing r <br /> ❑ Domestic/Private ID Gravel Pack ❑;Tracy 7s Type of Casing Specifications <br /> I1 Public f 1 Other R.Delta t Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth 1 l Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ { <br /> Well Destruction ❑ Well Diameter : ' .Sealing Material (top 501 l� <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-": AIR/ADDITION LI DESTRUCTION i I (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Residelcg�ommerc`ial Other <br /> Number of living units: Number of bedsr <br /> Character of soil to a depth of 3 feet: ` roa Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CogerP�*Vs _Capacity / � No. Compartments <br /> PKG. TREATMENT PLT. ❑ 3 Method of Disposal <br /> Distance to nearest: Well Foundation /10 Property Line <br /> t ^ <br /> LEACHING LINE LVNo &.-Length of lines M v Totallength/size <br /> / � <br /> FILTER BED ❑ Distance to nearest: Well Foundation _72,,� Property Line <br /> SEEPAGE PITS 1,1­�pth Size 731-- Nupber <br /> SUMPS L Distance to neare$t: Well� � Foundation Property Line ` <br /> DISPOSAL PONDS ❑ s <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: "I certify that in the performance of the work for which this permit is issued, I shall rio� <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 compen ' <br /> doof 4. -- a F <br /> The applican all r al �11 fCs C drawing on re a side. Q` <br /> Signe tle: Date: ✓ + r✓ <br /> t I <br /> FOR DEPARTMENT USE ONLY l p <br /> ` Application Accepted by ' Date L7 Arna I fi <br /> ,Pit/or Grout fnspectinri by Date Final Inspection by, Dat M <br /> CAdditional Comment !!! <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> r T � <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. l <br /> +�-l�/hy r <br /> ♦.EH 13-24(REV. /nsl f v <br /> EH 144-28 <br />