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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 described. This application is <br /> ` made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> ` Local Health District.' <br /> Job Address X r� 3 J U nt°6 n .--Q Q City im w Lot Size PM <br /> r <br /> Owner's Name G1AS Address J�t�^-G 4 Phone <br /> Contractor r L r L Address_ktL 16 D ! License No. Phone d �`l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 17 <br /> DISTANCE TO NEAREST: SEPTIC-TANK- SEWER-LINES DISPOSAL FLD. PROP. LINE V <br /> i FOUNDATION AGRICULTURE WELL W OTHER WELL PITS/SUMPS Y=' <br /> INTENDED USE TYPE OF WELL f'PROBLEM AREA CONSTRUCTION SPECIFICATIONS [ <br /> El Industrial E] Open Bottom ElManteca" " Dia. of Well Excavation Dia. of Well Casing <br /> ;". <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy�ff"� . x",(Type-of Casing — Specifications <br /> 13 Pubic ❑ Other ._ �❑ Delta I +s °-'Depth of Grout Seal Type of Grout 1 <br /> ❑,Irrigation �4pprox. Depth ❑ Eastern 1 Surface-Seal Installed by%` <br /> Repair Work Done ❑ Type of Pump. H.P. Staie'Work Done <br /> -F Well Destruction ❑ Well Diameter " <br /> -i Sealing Material Itop 50'6�+i <br /> Depth Filler Material {Below 501 <•< <br /> ""- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑--REP.AIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 4 available within 200 feet.) <br /> Installation will server Residence_. Commercial"A°` Other.- <br /> Number <br /> ther Number of living units: _4__, Number of bedroo_m!s A <br /> Character of soil to a depth of"3 feet " YS L1 S� Water table depth ; <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ "" Method of Disposal <br /> i .; Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ��� Total length/size <br /> i <br /> FILTER BED ❑.. Distance to nearest: Well 3 <br /> . .� Foundation� Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r a <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 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 /> 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 must call for all required inspections. Complete drawing on reverse side. -' <br /> Signed X jrt) ,t &4t Title: Date: t <br /> IV­ A <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by afe Final Inspection by Dateki <br /> 3 7 <br /> * Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 <br /> j Applicant- Return all copies to: Environmental Health Permit/Services 1601_E. Hazelton.Ave.,..P.O. Box 2009, Stk., CA 95201FEE <br /> . <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY F i ;, OATE PERMIT NO. <br /> +.EH18-24(REV.,/s51 ^7O, /$.-7 ^7-�r <br /> EH 1428 — <br />