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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZEL T ON AVE.; STOCKTON, CA i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lComplete 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 /> Job Address Od ^F111( City Lot Size /S ' -erw Q PM <br /> 16 Owner's Name L4 - Address`", E � s Phone•- <br /> `� r r� fjj <br /> Contractor _—.License_No. -- J .Phone i2 Z• '��� <br /> TYPE OF WELL/PUMP: a 'NEW WELL`-.0 A WELL REPLACEMENT 17 DESTRUCTION,0; <br /> PUMP INSTALLATION 0 '""'" - SYSTEM..REP,AIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE rt� <br /> FOUNDATION AGRICULTURE W£tL OTHER WELL + ,:PITS/S0MP1S; • . <br /> INTENDED USE TYPE.-OF WELL,I- PROBLEM AREA CONSTRUCTION SPECIFICATIONS rte•� r�� � ��:d <br /> ❑ Industrial ❑ OOee Bottom' z 1 ❑ Manteca Dia:of Well Excavation---- Dia. of Well Casing�*F <br /> # ' <br /> 0 Domestic/Private ❑ Gravel Pack � ❑ Tracy Type of Casing Spec�cations� <br /> ❑ Public ❑ Otger ❑ Delta Depth of Grout Seal r Type of Grout I <br /> [I Irrigation eQpprox. Depth- El Eastern Surface Seal Installed by <br /> rte. ' `� � (.-r' �H.P. � State Work Done � I <br /> Repair Work Done# ❑ Type of Purtlp .� � <br /> Well Destruction ❑ Well Dias `ter r Sealing Material (top 501 _ t <br /> Depth 3.z Filler Material (Below 501 : <br /> TYPE OF SEPTIC WORK: NEW(INSTALLATION 0-1 REPAIR/ADDITION DESTRUCTION ❑ (No septic system,permitted ifpublic sewer is <br /> j `�:, ✓ µms' available wiijhih-200 feet.)- `, .�,• <br /> Installation will serve: Residence Commercial°3 Other t <br /> Number of living units Number of-bedrooms' <br /> Character of soil to a depth of 3 feet: 92f f ---------euWater...table depth ° �I <br /> SEPTIC TANK i ❑ Type/Mfg k Capacity No. Compartments ` <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r € ` <br /> Distance to nearest: Well' Foundation Property Line <br /> I � 6 � � <br /> LEACHING,CIINE ❑ No. &Length of s Total length/size <br /> FILTER BED, ❑ Distance to ne reoundation Property Line <br /> t ; .: I ` <br /> SEEPAGE ITS' ElDepthj' 2 � Size . r umber <br /> SUMPS ElDistance to nearest: Weil 6(3 foundation Property Line <br /> DISPOSAL PONDS ❑ i f <br /> hereby certify that I have prepared this"eppiication:anh1that 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. ,. l <br /> Home owner or licensed agent's signature certifies the"following: "I certify that in the performance of the work for° ich this permit is issued, I shall not <br /> employ any personrin 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." '­', e, - _ -� I <br /> The applica must call f II require spections. Complete drawing on reverse side. <br /> 1 `.1 [ <br /> Signed A Title: la_rA!tn' _ Date: <br /> i FOR DEPARTMENT USE ONLY !� <br /> Application Accepted Date Area <br /> 'Pit or rout Inspection Dat �a1�`� -1 Final Inspection by Date <br /> r tet- 6\ L <br /> Additional Comments: 00 <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 " ❑ Tracy t 83;-x6385 <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 CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH13-241REV.1/55) <br /> EH 1426 <br />