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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 HealthDistrict 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. <br /> 548 for-sewage or No 1862 for well pump and the Rules and Regulations of the San Joaquin <br /> Loco! Health District! <br /> .lob Address <br /> L/ 7 a9`1e �' City C /J'f d Lot Sizey ~• PM <br /> 1�Iro 3Gcl, �l i Phone <br /> Owner's Name Address _ <br /> r ��► C9�_ — Phone <br /> Contractor's Name 4e License No. c <br /> TYPE OF WE NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWEfl LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Q Industrial 0 Open Bottom ❑.Manteca Dia. of Well Excavation QQ <br /> n <br /> ❑ Domestic/Private ❑ Gravel Pack Q Tracy' Type of Casing Specifications <br /> LN <br /> Type of Grout --� <br /> C1 Public El Other F-1Delta` Depth of Grout Seal <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seat Installed by k N <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ID Well Diameter Sealing Material (tap 501 <br /> k Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailabpelwit Sn 200 feet.) if public sewer is <br /> r Installation will serve: Residence_ Commercial Other i <br /> I4 Number of living units:--I— Number of bdrooms p <br /> Water table depth <br /> Character of soil to a depth of 3 feet: � <br /> Qa z r � 61pacity� No Compartments <br /> SEPTIC TANK B,—Type/Mfg {- <br /> PKG. TREATMENT PLT. ❑ ' `Method of.Disposal <br /> t?�' 0 r Pro ort Line <br /> Distance to nearest: Well Foundation p Y' . Q <br /> ,. D'- Total length/size <br /> LEACHING LINE f�No. & Length of lines 1 (�t Property Line _— <br /> FILTER BED ❑ Distance to nearest'. Well 1.10 - Foundation <br /> r�v <br /> SEEPAGE PITS Q 3' Depth 42 _Size Number <br /> SUMPS ❑ Distance to nearest: well�s.L� Foundation__5_5 t= Property Line a r <br /> DISPOSAL PONDS 11 / a <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 District. <br /> I 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.' w ' <br /> I The applicant must.call or al required inspections. Complete drawing on reverse side. �n7 <br /> Title: <br /> (,c��C Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> ' ., Date � Area <br /> plicy Date <br /> ation Accepted by � <br /> Q1? — <br /> ��F-i , Grout Inspection b <br /> Date`� �'�� � Final Inspection by _ , <br /> } Additional Comments: <br /> El Stk 466-6781 F-1Lodi369-3621 13 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 , <br /> FEECK RECEIVED 9Y DATE PERMIT'NO. <br /> INFO 5AMOUENTDUE AMOUNT REMITTED CASH o3g <br /> + EH 1324 IREY.10/831 _ <br /> EK 14-26 <br />