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(_'N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplidate) <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 I Ilwy 88 City Lockeforot Size PM l <br /> Owner's Name AJN * t]3slrbA!* _ Address �r Phone <br /> J1 ,.Phone727 3119- <br /> Tla �r W�11 Drill Name se <br /> TYPE OF WELL/PUMP: NEW WELL m WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANK `� SEWER LINES"­ DISPOSAL7-FLp:-__--PROP7LINE`__J4 -`� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11Industrial it Open Bottom ❑ Manteca Dia. of Well Excavation 7 Dia. of Well Casing <br /> JJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .125 wall rnn <br /> ❑ PublicDther El Delta Depth of Grout Seal f Type of Grout ! <br /> UV1 �fl <br /> 13 Irrigation "�pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done �—«'Type of Pump _ H.P. 11 �4 <br /> State Work Done e ' <br /> Well Destruction ❑ Well Diameter Sealing 11Aaterial'ltop 50 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.0 ,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: ,- - Number�of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityT No. Compartments <br /> PKG. TREATMENT PLT. 17 Method of Disposal <br /> L <br /> Distance to nearest: Well Foun ion Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: We Foundation Property Line <br /> SEEPAGE PITS El Depth.. Size _ Number- <br /> SUMPS <br /> umber SUMPS ❑ Distance t earest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ y � <br /> I hereby certify that I have An ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations o e San Joaquin Local Health District.' ly <br /> Home owner or licerifed 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." <br /> Theappkicant u ;requi4ked ' spections plete drawing on reverse side. <br /> Signed e: Date: v <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by�! / Date �/ Area <br /> Pit or Gro t Inspection by Date � r �! GFinal Inspection by Dat s' <br /> Additional-Comments: <br /> D 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, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH I RECEIVED BY DATE PERMIT'NO. <br /> INFO ` <br /> + EH 13-24 IRM 101831 <br /> EH 1426 <br />