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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> € 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> # Job Address d &'Olf2A 4 nJ City GLot Size - PM <br /> ` Owner's Name AA,074 Pldfoqi. Address chi! Phone <br /> F Contractor r Address License No v`` 2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ( ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Casing Specifications <br /> I1 Public n Other f7 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') r <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1.1 DFSTRUCTION i I (No septic system permitted if public sewer is t w <br /> available within 200 feet.) <br /> i <br /> k Installation will serve: Residence Z Commercial_ Other <br /> Number,.of-living-.units: — <br /> F- .- <br /> Character of sail to a depth of 3 feet: - IVA. Water table depth L ; <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No: Compartments <br /> PKG. TREATMENT PLT. 0 � Method of Disposal ` <br /> Distance to nearest: Welly Foundation Property Line�G�_ <br /> LEACHING LINE No. & Length of lines �� .y�Toottal�length/size <br /> FILTER BED ❑ Distance to nearest: Well 219[5 Foundation -_ Property Line ` <br /> SEEPAGE PITS 1 Depth Size _ Number I l <br /> SUMPS ❑ Distance to nearest: -Well Foundation. T Pioperty Line <br /> El <br /> DISPOSAL PONDS «> <br /> i <br /> I hereby certify that I have prepared this application and that the-work-wit`k5e:done-Ui-accordanCe with-San Joaquincounty ordinances, state laws,'and C <br /> rules and regulations of the San Joaquin Local-Healtts District i e <br /> Home owner or licensed agent's signature certifies-the following:-'1-certifyrthat in!the performance-of the,work-foi which this permit is issued. I diall not <br /> employ any person in such manner as to become sugiect to,workman's cortlpensation laws of California."Contractor's hiring or sub-contracting pesignature <br /> certifies the following:"I certify that in the rformance-of the work,for-which this perriiit-is issu'edri shall'employ personssubject to workman's competure <br /> tion laws of California." w ;' <br /> nsa- <br /> ..rte-.• '� r - <br /> The applicant.must.cali for a required inspections. Camplete drawing on reverse side. <br /> Signed X_ GCS .��i Title: r Z,? <br /> a Date: <br /> i l k /r-O ARTMENT UStE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection-by i Data Final Inspection)by Date r�; <br /> F ` <br /> Additional Comments: 101, <br /> ❑ Stk` 4666781 ❑ Lodi 369-3621 ❑Manteca 823-7104 ❑ Tracy 835-6385, <br /> Applicant - Return all copies to: Environmental Health Permit/jervices 1601 E. Hazelton Ave., PA Box 2009, Stk., CA 95201 I <br /> FEES - CK- <br /> UN <br /> ""AMOUNT DUE"" �`,Ah O't RE4AITfED _ - ,RECEIVED BY - -DATE -_ PERMIT <br /> INFO .CASH _ _ _ _ <br /> + EH 13-24 1REV.I H 5; _ <br /> 1 EH 1428 %_76 <br />