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I APPLICATION FOR PERMIT <br /> Vr o�6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT bo <br /> 1601 E. HAZELTWAV,E-, STOCKTON, CA <br /> Telephone (2091 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address m A f City _50111,11, t Lot Size PM <br /> C .� <br /> 9 <br /> Owner's Name Address ,kQgZ �Ddlrf`ol0� /Gdr Phone <br /> :I y <br /> Contractor � { Address / � x �Z License No: ( Z 3 7 Phone 6 rf6 Z� <br /> 16 TYPE OF WELL/PUMP: ;I` NEW WELL ' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLAT_10N 6, _ '` i SYSTEM REPAIR-'LY'ti� _ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES � ^ l DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIC, <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca �' Dia. ofWellExcavation Dia. of Well Casing <br /> RRIDomestic/Private rave! Pack ❑ Tracy Type.of Casing iV G Specifications <br /> t f`] Public +, �116_Approx,,Dep <br /> ther Cl Delta Depth of Grout Seal Type of Grout <br /> l Irrigation �` astern .1 <br /> r/ a/Seal Installed b - <br /> Repair Work Done ❑ Type of Pump H.P. <br /> 1 Y 1 State Work Done r ' <br /> k _ � <br /> Well Destruction; LK/Well Diameter Sealing Material;lt I <br /> ,Filler Material IBel 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTAt`AT1014:11 •,REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 1 Installation will serve: Residence— Commercial, -Other <br /> Number of living units: ',Number of bedrooms s , <br /> i Character of soil to a deptFi�of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl / / Method of Disposal <br /> 11 <br /> i Distance to ne6rest: well Foundation Property Line <br /> a LEACHING LINE .yf ElINo. & Length of lines >. Total length/size <br /> FILTER BED -❑ . Distance`ta nearek ; 'Well Foundation Property Line <br /> SEEPAGE PITS a1.IDepth Size Number <br /> ;SUMPS { ` Ll Distance to nearest: Well, • Foundation Property Line <br /> -DISPOSAL PONDS ❑ I� ��� <br /> I hereby certify that I have prepared this applica&rt.a"id that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules OC.aliforn <br /> San Joaquin.Ljcal4',Health Di$trict.*, <br /> Home Ice sod ag It's signawre certities the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> emploin'such nner as to become.subject to work m n's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifiing: "I cartir that in the perforrnan o the r or which is permit is issued, I shall employ persons subject to workman's compensa- <br /> tion larniThe at 11 fo all r uired i pe A pl drawing r <br /> I Signed <br /> ��/te:Da <br /> ENT_USE ONLY C, 3. <br /> Application Accepted by Date S~ i�� -.... Area , <br /> Pit or Grout Inspection by Date Final Inspection by Da <br /> # Additional Comments: C�& <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 © Tracy 835 5385. <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> gFEE- - ' <br /> `INFO BUNT DUE" " I+,�MOUNT IiEM177ED'" CASH RECEIVED BY PATE PERMIT'NO. <br /> +.EH 13-24(REV. /H 5) <br /> EH 14-26 V v <br />