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APPLICATION FOR PERMIT <br /> 2A• fY-a T Y. <br /> SAN JOAQUIN'LOCAL'HEALTH DISTRICT <br /> 44� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6* <br /> PERMIT EXPIRES 1'YEAR FROM DATE 'ISSUED <br /> (Complete in Triplicate) <br /> �. <br /> rp '4r :r 1-, - `;i{ TL >, r37, t�' : ?''��CP 7 <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. �'/z*y//f e x _. ,•-., <br /> �� VL� <br /> Job Address l "• ' j ` ` „I F } '? <br /> City`/lC� of Sizey - PIIA <br /> . - �• �:� ,..� ,. �a s`t,.fir, ,. . ,.So-; ,..,� ;;'I -,:9 '�i� <br /> Owner"s Name&4V Address =Phone <br /> Contractor dkeAddress A&& License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION K SYSTEM REPAIR,[) OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zai <br /> ❑ Industrial El Open Bottom 1-1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> l o< ticlPrivate Gravel Pack ❑ Tracy Type of Casing Specifications y <br /> ❑ Public ❑ Other .❑ Delta Depth of Grout Seal Type of Grout <br /> ElIrrigation- Approx3.. Depth <br /> 'yam❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump �Ub H.P. .3 State Work Done 1I'7S-6 ki S(3 <br /> Well Destruction ❑ Well DiameterZ�r <br /> _�_, Sealing Material {top 501 <br /> Depth `�`0 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i. available within 200 feet.) . <br /> Installation will serve:: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> F'. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. 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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size' Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property.Line <br /> DISPOSAL PONDS ❑ t <br /> 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. <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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." t y <br /> The applicant must Call for all required inspections. Complete drawing on reverse side. Q <br /> Signed Title:-� �1l�sy ��_.____ Date ZZ— <br /> 7-9Z <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Z _Area t3 <br /> Pit or Grout Inspection by '""`'` Date Final Inspection by Date <br /> Additional Comments: 7 �- -. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 160f E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. <br /> �. 7 <br /> INFO AMOUNT DUE AMOUNT REMITTED FEE <br /> Sip CASH RECEIVED BY, DAVE) PERMIT`NO. �//{ <br /> +EH13-241REV.t/s51 .i��,1 <br /> EH 1426 <br />