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APPLICATION FOR;PERMIT <br /> SAN JOAQUINILOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 'AVE., STOCKTON, CA . <br /> Telephone (209) 466-6781' <br /> -";"7 <br /> PERMIT EXPIRES.1,YEAR FRAM iDATE Ir4FSSUED <br /> t:_Itk :vr^ {Complete.in Triplicate),;k"- .�, P <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described:Thii application is <br /> made in compliance,with San-Joaqujn.County.Ordinance'No:-545:for,sewage�or,'Noc-1862.for well/pump and•the Rules and Regulations of the San Joaquin \ <br /> Local Health District <br /> .4te3a <br /> ^' Job Address Cy[t/ ���.��, m City Lot Size �,�cais•, cQM <br /> Owner's Name Address 4Phone - <br /> Contractor's Name I se P L A d4: <br /> License No. gxs Phone [ vp, -7 r <br /> TYPE OF WELL/PUMP: NEW WELL) WELL REPLACEMENT ❑ DESTRUCTION <br />,. PUMP INSTALLATION',K -: SYSTEM,REPAIR ❑ OTHER ID- V <br /> DISTANCE TO.NEAREST:.SEPTIC;TANK. 1.26 I SEWER LINES JS-j D ` DISPOSAL FLD. ISO PROP. LINE &�d_` <br /> FOUNDATION AGRICULTURE WELL°__Xj�Q�OTHER WELL-__'�'�" PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> --❑ Industrial -- ❑ Open Bottom ❑ Manteca. Dia. of Well.Excavation. Dia. of Wel! Casing si <br /> (,Domestic/Private `Gravel Pack O Tracy Type of CasingL1lrC Specifications ./Et) <br /> } - ❑ Public ❑"Other.,; t ❑ Delta Depth of Grout Seal Type of Grout <br /> Irri ation----f --- pt stalled by <br /> g -�.,.a.�-^...._....Approx:�De ham.... <br /> Repair Work Done ❑ Type of Pump �u��Easter�r�.,,,`;�..._S���e Seal In State Work Done <br /> Well Destruction Well Diameter �, Sealing Material (top 50') C_ eN 'eAl <br /> Depth Filler Material f8elow 50'1 V dtt- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.El REPAIR/ADDITION,❑ DESTRUCTION'❑ (No septic system permitted if public sewer is <br /> serve: .µResidence� Co - - available within 200 feet. <br /> Insta'nsa - mmercial_ Other <br /> Number"of living Number of bedrooms <br /> Character of soil to a depth'o ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 5 <br /> 'Distance to nearest:' 7we�ll ­ <br /> n Property Line <br /> LEAGHlNG'LINE ❑ No. & LenBth'of lines Tota ze <br /> i FILTER BED" t—❑ Distance to nearest. "Foundation Property <br /> .r. <br /> SEEPAGE PITS ❑ Depth Size i 1 Number <br /> ❑. Distance to-nearest: Well° Foundation Property Line ' <br /> R <br /> t <br /> i DISP�"PONDS: 0� i <br /> hereby certify that.l have prepared thi plic8tivn-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 A.. - •- <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, l shall not <br /> employ.any person in such manner as to become subject to workman's compensation laws of California."Contractdes:hiring.or.sub-contracting signature <br /> certifies the following: that in the rformence df the work for which this permit is issued;)shall employ persons subject.to workman's.compensa-, <br /> The ion lawli ant must call lfor arlly pe <br /> of Cafirfornia.'� <br /> pp -required ins ctions»Complete drawingside. <br /> Signed x Titleon reverse te: <br /> Da / <br /> FOR DEPARTMENT USE,ONLY <br /> Application Accepted by W Date b���3'" _ Area <br /> 1Z <br /> 1 a.y_ Pito Grout nspection by Date 1 "`l ' Fina! Inspection by Date1. <br /> - ., .. _ , ...- +,� <br /> _. : %'Additional Comments: <br /> ❑ Stk''466 6781 -❑ Lodi -369-3621 ❑ Manteca,'623-7104 7..' racy 835-6385w✓G.1 v►:-�'.�- <br /> he') , <br /> Applicant- Return all copies to: Environmental Health Permit/Services'1604 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1jr <br /> �r✓� <br /> c+ � <br /> f~ INFO AMOUNT DUE , AMOUNT REMITTED CK' <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> 4 EV.10 <br /> EH 1 <br />