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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZELiON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .This <br />` Application is hereby made to the Joaquin Coungty OrdinajnHe No.549 for sewage ealth District for a o rNo�1862 forcwe I/dp and/or <br /> and the.Rul s and herein <br /> R Regulations of the Sancation is <br /> J6aquin <br /> made in compliance with San Jo q L <br /> Local Health Districts <br />+ � Lot Size PM <br />` City <br /> 1 Job Address <br /> J Phone <br /> Address <br /> Owner's Name _ <br /> "W M_......w �Q Lice` n^se No. �a�. --Pho e 3 �7 <br /> Contractor d Address <br /> TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR 1-1 <br /> OTHER ❑ <br /> f DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK--, SEWER LINES -_�-- a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing � <br /> ❑ Industrial ❑ Open Bottom '❑ Manteca Dia. of Well Excavation 5pecificatians <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy . Type of Casing <br /> ❑ Delta r Depth of Grout Seal Type of Groin <br /> M Public ❑ Other �-� I <br /> - I ! Irrigation �..Approx. Depth I I Eastern Surface Seal Installed by <br /> t H.P. i Cil State Work Done <br /> Repair Work Done ❑ Type of Pump t <br /> Scaling Material Itop 5011 t <br /> Well Destruction , Cl Well Diameter g <br /> Depth ' Filler M 11 aterial (Belood <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I RLv,AI IJ�fSDIT16N„l I' Df�TRUC710N I I availablerc system wthin 2W feet.) <br /> it public sewer is <br /> "Commercial_ i, Other <br /> Installation will serve:--Residence } <br /> Number of living units:, -Number�t ooms= ... Water table depth <br /> _ Character of soil to a depth of 3 feet: ” G49�� <br /> s/ ,Ca acct No. Compartments <br /> SEPTIC TANK II�Type/Mfg — p--Y t <br /> 'y1-. I V Method of Disposal <br /> PKC. TREATMENT PLT. ❑ >" �0/ <br /> r'� d d0 1 Foundation d , Property Line_� <br /> Distance to n�aresi' Well 110031 Foundation t. <br /> Total length/size <br /> LEACHING LINE -4l.-Vo. & Length of lines <br /> "'��Distance to ne arest: Well f 0a► Foundation—Z[�— Property Line <br /> FILTER BED <br /> SEEPAGE PITS l*--Depth 42 ' Size <br /> Number <br /> SUMPS "' Ll Distance to nearest: <br /> well 0 Foundation �S! Property Line <br /> r <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquint county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di?;trict. 1 �• <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 /> I employ anyiperson in such manner as to became subject to workman's compensation laws of California." Contracto'r's hiring or sub-contracting signature <br /> certifies'ttie followin I cert�rthat in the p rformance of the work for which this permit is issued,l shall employ per subject to'workman's compensa- <br /> tion laws of Callfornia." <br /> The applicant must call for all req ed inspections. Complete drawing on reverse side. / <br /> f i{ Title: Ak <br /> t Date <br /> Signed X t 0 ; <br /> i FOR DEPARTMENT SE ONLY <br /> 4 Date "Area <br /> Application Accepted by <br /> it or Grout Inspection byir <br /> Date Final Inspection hy" Date <br /> c� <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Silo, CA 95201 7 <br /> FEE <br /> CK <br /> t RECEIVED BY DATE PERMIT'NO. <br /> �. AMOUNT DUE AMOUNT RSMITT,ED <br /> INFO <br /> +,EH13-24(RM 1/Rs1 <br /> EH 11.26 <br />