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►} 7 <br /> ES- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �C�4wv4V14vr.� <br /> 1601 E. HAZELTON AVE.,-STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1.YEAR FROM(DATE ISSUED T I <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 - 1 _.O s � �� e ` ± Lot <br /> t Siz <br /> City `• Lot Size PM - <br /> Owner's Name 421001;I WYAI C.fIELL Address" PhoneT <br /> Contractor j54ndy-P a. LtJc!~ 2 Address_gieC A 41 t.L-!A.r✓ A4 Licensel'No.�� 2.7�Phone !�_44 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL:FLD.! PROP. LINE <br /> FOUNDATION 9 AGRICULTURE WELL ! OTHER WELL PITS/SUMPS _ <br /> 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 /> ❑ Public#% ❑ Other ❑ Delta Depth of Groutr-Seal—_ -- - Type of Grout (� <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ' ❑ Type of Pump 1 H.P. State Work Done <br /> Well Destruction ±y,❑ Well Diameter # Sealing Materialyltop <br /> ,(-""Depth Filler-Mateate al (Below 501 I n <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: ;Numljer of bedrooms <br /> l 1 <br /> Character of soil to a depth of 3 feet: ' : Water table depth p <br /> y t <br /> SEPTIC TANK ^,Type/Mfg 1 'Cappcity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � ' r Z "I Method of Disposal l _ <br /> v.t • "F.y. I <br /> Distance to nearest: t{Nell Foundation _Property Line <br /> LEACHING LINE ❑ No.'&Length of lines , Total length size{ <br /> E <br /> FILTER BED EDDistance.to nearest: Well Foundation "Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth , .. .Y SizeNumbers j <br /> F ," <br /> SUMPS. 1-1Distance to nearest:" Well Foundation-•� Propertyr'Line- <br /> DISPOSAL PONDS ❑ <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 and regulations of the San Joaquin Local'Health District. I <br /> Home owner or licensed agent's signature certifies the following- "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 perform nce 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 must call for all required inspections. o tete drawing on reverse side. <br /> Signed �� Title: __C_et�� Date: 3-12_40;? <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �`�" Area <br /> Pit or Grout Inspection" Date - Final Inspection by Date <br /> Additional Comments:, Yi_�0), <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man 823-7104 ❑ Tracy 835-6385 als�X- <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.0 20Q9, Stk., CA 95201 <br /> INFO AMOUNT DUE i AMOUNT REMITTED CK H RECEIVED BY, DATE PERMIT NO.' <br /> r y�- <br /> + EH 13-24(REV.I/H!,) [J ® <br /> EH 1428 �j <br />