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APPLICATION FOR PERMIT , <br /> 4 SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E.`.hN E.1.71 ON AVE.;.STOCKTON, CA <br /> Telephone (209) 466-6781_ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)W ),,6-T OF f�7� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const�ct and/or install the work herein described. This application is <br /> Y 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 /> I Local Health District. , w <br /> Job Address y� A� City' 5 ZZ- ) Lot Size PM <br /> Owner's Namedress l - Phone ' <br /> Contractor Address� � GG1/� License No.�_oCs.__ 86 phone <br /> TYPE OF WELL/PUMP: NEW WELL N WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 2 SYSTEM REPAIR ❑ OTHI jR ❑ / <br /> DISTANCE TO NEAREST; SEPTIC TANK _ SEWER LINES DISPOSAL FLO. f-0- PROP. LINE <br /> f J�FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS <br /> INTENDED USE { TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> [I Industrial ,ff ❑ Open Bottom El Manteca Dia. of Wel! Excavation Dia. of Well Casin <br /> Domestic/Private 1 �.>oGravel Pack ❑ Tracy Type of Casing—_ / Specifications r <br /> ❑ Public ❑ Other El Delta Depth of Grout Seal _ Type of Grout C <br /> ❑ Irrigation e�4pprox. Depth'❑,�Eaastern S�rfeee Sea] Installed by <br /> Repair Work Done ElType of Pump �9 H.P. 7;?__ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> II SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size i <br /> FILTER BED D Distance to nearest: Well Founaatign �- Pr-op".-Line_ <br /> SEEPAGE PITS b Size <br /> Depth `�'` <br /> Number <br />! SUMPS �1 Distance to nearest: —1Nell- - Foundation Pro a Lin' } <br /> DISPOSAL PONDS d . p � �� <br /> � i 1 } <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 arid regulatia s of tF3e San Joaquin Local Health District. ,� ii <br /> Home owhei or lice, ed gent's signature certifies the following: "I certify that in the performance of the work for%vhick this permits issued?I shall not ' <br /> employ any person 1 suc 1 man or as to become subject to workman's compensation laws of California."Contractor's Wiring or sub-cbntraeting signature <br /> certifies the followin�:'I card'.. hat in thperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Ca(ifornie." 1 II _ <br /> The applicant f r all re i specti ns. Cortplete drawing on revs ide. <br /> Signed ----Title: J Dater : y �` <br /> €. FOR DPAFtTMENT USE ONLY <br /> A <br /> Application Accepted'by / Mate <br /> IL <br /> Pit or Grout lnspection,by Date�t - Final InspecV6 by r �Date <br /> r s -- _ (1 `--h � �Or f <br /> Additional Comments- A2 IV / it <br /> ❑ Stk 466-6781 ❑"Lodi _3W-5-11-- El Manteca 823 7104`''° EI Tracy,_83�5 r�/� �! !� <br /> Applicant- Return all copies to Permit/Environmental HA6 Services 1601.E.,Hazelton Ave., P Box-2009;Stk.,_CA 9 0FEE <br /> 1 +` <br /> INFO AMOUNT DUE r AMOUNT REMITTED` CASH RECEIVED BY DATE I PERMIT`NO. <br /> + EH14281REV.5/651 Ch O %T7—1 J / f f, <br />