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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> t Job Address ayp s Cbrnals . _AUL City Lot Size la X2296- PM <br /> Owner's Name d AR&V _. IrAaA 6 Address 0GS' Cr" �a Phone <br /> I Contractor AMIP, Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑fr <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -'PROP,;LINE_ <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑1 pen.Bottom El Manteca Dia. of Well Excavation ll Dia. of Well Casing <br /> �omestic/Private ;_ _'Gravel Pack' El Tracy '� Type of'Casing 1 « C, Specifications <br /> t : <br /> M Public Ll Other I;l Delta Depth of Grout Seal a f A TI N t7l—-�t J ` �\ <br /> ] Irrigation .Approxi Depth `l'I Eastern - _..r.$urface Seitl_Instailed by Ji,GAi 3A[& 13 .5• <br /> Repair Work Done' ❑ Type of PumYKF- �. H.P. /T� State Work Done_ C} <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> wf Depth Filler Materia!16e1ow'50'1vY lJ� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION (,I DESTRUCTION { I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> i Installation will serve: Residence_ Commercial_ Other <br /> I Number of living units: -Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg '' ' "Capacity^`" No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> � t� <br />€ Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines. Total length/size r. `Qn' <br /> f FILTER BED ❑ Distance to nearest: r Well Foundation Property Line V <br /> SEEPAGE PITS I I Depth Size _ Number <br /> -SUMPS -• - ❑ Distance to nearest: Well Foundation` `' Property Line :. <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 county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. A <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 /> II 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 compansa- <br /> tion laws of California.".t44 <br /> The applicant must-call-for- I required inspections• Complete-drawing on reverse•side: - -.A- <br /> Signed X Title: __ L/- Date: <br /> FOR.DEPARTIWENT USE ONLY <br /> Application Accepted by Nw � 1..�.. _ Date TL^ y Area Qr� <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: a/f . x 70 <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM IT*NO. <br /> INFOi1 ASH <br /> ` + EH 13-24(HEV. <br /> r/x51 <br /> EH 14-26 ' <br /> ice' <br />