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APPLICATION .FOR..PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TOWAVE., STOCKTON, CA <br /> Telephone.(209) 466-6781- <br /> - T4:.4-,tv I A vr <br /> PERMIT EXPIRE' 1-YEAR FROM.-DATE ISSUED <br /> -3,.(C.ompletein.Triplicate),.r -,"?� tf- f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereVd'esc66ed.­This appli6atibn is <br /> made.in compliance With San Joaqbin County Ordinan.ce'No.-549 for-sewage or No. 1862for well/.purbp and the Rules-and Regulations,&the San Joaquin <br /> Local Health District.-_ <br /> Job Address Ci N Vt1t F� <br /> lz� <br /> Owner's Nam 11 I�W Address <br /> Phone <br /> Contractor's Name k License No. I L�9 _)_1 Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT El DESTRUCTION El <br /> PUMP INSTALLATION. 0 SYSTEM REPAIR [I OTHER 0' <br /> DISTANCE TO NEAREST: SEPTIC,�TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL.—.OTHER WELL PITS/SUMPS <br /> INTENDED'USr TYPE OF WELL PROBLEM'AREA POWSTRUCTION SPffCIFICK-_C1.6P4S <br /> E.] Industiial -CI Open Bottom El Manteca Dia, of Well Excavation Dia. of Well Casing <br /> EJ Domestic/Private ".i 0 Gravel Pack 1-1 Tracy Type of Casing Specifications <br /> El Public <br /> 0 Other [I Delta Depth of Grout Seal Type of Grout <br /> — <br /> 1:1 Irrigation ---Approx..Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction El. Well Diameter Sealing Material (top 50').' <br /> Depth Filler-Material-{Below-W-). <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION L-ATffPAIR/ADDITION D DESTRUCTION.0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R 'dance_Commercial Other (T <br /> 7 <br /> Numl6e't of living units: Number Tedr'ooms <br /> .i 1, 1- <br /> Characier of soil to a depth of 3 feet:,— b —Water table' depth <br /> SEPTIC TANK ::I]L__Type/Mfg Ln�lr, t F= No. Compartments <br /> Capadity_= <br /> PKG,'_TREATMENT PLT. 0 t Method of Disposal' <br /> Dista.nee to neare!p well. Foundation Property Line <br /> i IV\Li C V\1 <br /> LEACHING LINE L . & Length of lines <br /> Total length/size <br /> -FILTERB.ED Cl- Distance to nearest:. Well Fo'urid'at'ion Property Line <br /> SEEPAGE PITS �8pth -size; Number— <br /> SUMk 0 Distance to nearest: Well <br /> " Foundation Property Line <br /> DISPOSAL PONDS' 1`7 T_ <br /> I hereby certify that 1:'.have prepared this application and that the work will be done in accordance with San ordinances,,state laws, and <br /> rules arid regulations of the San Joaquin Local-Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the,p6rf ormance 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."Contr6ctor'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 employpinsons sobject to workman's comppnsa- <br /> wn of Califo 'I <br /> ' <br /> 7h lic usrtca'l' .,I quires i`n��"' Complete drawing.oA reverse rVde <br /> S!a po _ � _9 ,- .. . . . 1. /t.-�,,, <br /> � A; D Date: n <br /> Signe Title:LADn Y <br /> FOR DEPARTMENT USE ONLY <br /> A <br /> Applibation Accepted by I r Date <br /> Area <br /> Pit or Grout Inspection by ate 1-11 5 Final Inspection by f-Mi6— Datd X`- -7-9 15 <br /> Additional Comments: <br /> C1 Stk 466-6781.... - EI Lodi 369-3621-- _T,[3,Ma" 823-7104, lk 0 Traqy,,835-6385:t_, <br /> CA'95201 <br /> Applicant- Return all copies to: Environmental Health Per�mit/SeNices%11601 C zeltonAve., -Vtk <br /> He P.O. 'Box 2DO9, <br /> hINFO FEE <br /> 'AMOUNT DUE 'AMOUNT REMITTED D CASH AECEIVIED BY DATE' <br /> +Em 13-2b(REV.10/83) <br /> -7-3 V li-4 <br /> EH 14-25 tj <br />