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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> '. PERMIT EXPIRES 1-YEAR FROM DATE ISSUED' ,. <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 Joaquln 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. .. . :c �, . y,V' <br /> Job Address 0 / ' ~ <br /> city St Lot Size l d xom__ PM <br /> Owner's Name RAR C) \1 1�rjLf�ly �E4 8 AddressPhone <br /> _ ~` <br /> SIL... —� <br /> "`Contractor L CE }( TJ AL L Address License No <br /> w Phone 7 <br /> TYPE OF WELL/PUMP: �� NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL:TURE-WEL'C"-'3 OTHER 4VEL"L `PITS%SUMPS_ <br /> l INTENDED USETYPE OF WELL 'PROBLEM AREA. CONSTRUCTION SPECIFICATIONS l 1 I <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> ❑ Public ❑ Others ❑ Delta Depth of Grout Seal <br /> ElIrri Irrigation Type of Grout <br /> 9 —�pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Dane <br /> Well Destruction 11Well Diameter <br /> Sealing Material trop 50'1 <br /> Depth Fiiler;Material (Below 50'.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 43EPAIR/ADDITION S7RUCTION ❑ (Na septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: 1 Number of bedrooms }� <br /> . Character of soil to a depth of 3 feet: L T <br /> SEPTIC TANKType/Mfg <br /> iWater table depth 444 <br /> ❑ Type fg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ "-- - ,�,,, A. <br /> `� Method of Disposal € ` <br /> Distance to nearest: Well. [ Foundation Property Line <br /> �I <br /> LEACHING LINE C[YAo. B,tLergthyoflines =-- Total len th/size <br /> FiLTER BED g <br /> ❑ Distance to % Well Foundation <br /> --c �— Property Line 2, <br /> SEEPAGE PiTS ❑ Dep4' Size Number <br /> SUMPS 'I k J a <br /> ibistance to nearest:; Well Foundation _ Property Line__�! <br /> DISPOSAL PONDS ❑ R :p 1 to S <br /> I hereby certify that I have pranJo ilihis application and that the work-will-be done in accordance with-San Joaquin county ordinanc s, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies ihe`iollowin F -- I <br /> employ an 9: "I certifyy at if the performance of the work for which this permit is issued, I shall not es <br /> p Y y person in such manner as to became subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> cert 'es the following: "I certify that iA the performance of,the work for which this permit is issued, I shall C employ tion la of Californ' p y persons subject to workman's compensa- i <br /> The applic ust ca for I requi d insIrons: �-plete�drawing on reverse side, -Si ne /`fJg ; Title: �. Date: <br /> OR DEPARTME USE ONLY . <br /> Application Accepted by 5 !r Date �4 <br /> Area <br /> Pit or Grout Inspection by Date / <br /> 1 t Final inspection by - Date E� � <br /> d 'ional Comments: <br /> 466-6781 ❑ Lodi 36913621 O Manteca 823-7104 M Tracy 835-6385 <br /> Appli ant- 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 K t <br /> INFO RECEIVED By . DATE PERMIT"NO. E <br /> + EH 13-24 EH 1426(REV.t/851 <br /> _ l <br />