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i <br /> Tic', J � <br /> APPLICATIONOR PERMIT <br /> 'Lo0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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. , r t <br /> S 2, <br /> Job Address City Lot Size PM <br /> rn _i ` 1 <br /> Owner's Name 13 1 S S'C� ��� Address — C]� �V 1— T Phone <br /> Contractor's Name r Jd C License No. ,� Q C7 Phone'• '/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 9. <br /> \,PUMP fINSTALLATION LISYSTEM REPAIR.;K OTHER ❑ / - <br /> " DISTANCE TO NEAREST:�SEPTIC"TANK --SEWER LINES DISPOSAL FLD./V_0`tPROP. LINE Z 5 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /_e Dia. of Well Casing. <br /> Domestic/Private: 19 Gravel Pack ❑ Tracy Type of Casing "S 7—e e L 126 c- Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth'of Grout Sealy` Type of Grout <br /> ❑ Irrigation ,5�fApprox. Depth Eastern Surf ce Sea]_Ihstal_le_d by <br /> Repair Work Done Type of P�,ritpH.P. State Work Dona P <br /> Well-Destruction - Well Diameter — i y}Sealing Material (top 5011, <br /> _ �wDepth_ 42 _ * Filler Material (Below 50') _� Ze,-- (a fry-,.a €? <br /> 001 <br /> t PE OF SEPTIC,WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ' available within 200 feet.) <br /> 'r Installation e: Residence= Commercial :Other Yf/ <br /> Number of Living units: Number of-bedrooms <br /> Character of soil,to.a depth of..3 — Water table depth <br /> y SEPTIC TANK j ❑ Type/Mfg Capacity_I No. Compartments <br /> �. . <br /> 4 PKG. TREATMENT PLT. LJ ` -. -zzf. w y 4 J -4 i Method of Disposal <br /> tA <br /> Distance-to rieirest: Well oundation- Property Line <br /> LEACHING-LINE No. & Length of iiries I length/size <br /> FILTER BED ❑ Distance to nearest: Well F Foundation Line <br /> SEEPAGE PITS El Depth Size } Number i <br /> SUMPS y ❑_ .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 an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> 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 compensa- <br /> tion laws of California." <br /> The applicant m II for all required 1'p ctio omp a drawing on reverse side. ! <br /> Signed Title: / Lit - Date: <br /> y <br /> I'"`el ° 00 SS FOR DEPARTMENT USE ONLY- <br /> Application Accepted by Date G Area /1? <br /> PitGrou Inspection by Date Final Inspection by Date �� <br /> Add'' al Comments: _ <br /> ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca -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 /> � r I <br /> " IFEO EE LAMOUNT DUE'1- AMOUNT REMITTED CASH CK RECEIVED BY 1^ DATE PERMIT"No. 5 <br /> +EH 13-24[REV.10/831 <br /> EH 14-26 1 c� <br />