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R Q APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E:�HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <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 Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> r <br /> Local Health District. <br /> �7 _ ' fiE'�1+1Gf1 e/�ic t,L7 I <br /> Job Address /y7'7 _/ d.L FIE Rol City Lot Size;!► C .PM <br /> Owner's Name /\ lef� /YT/ �/q/U�Address /3733 oe� 0 /'ir GS,lG Phone <br /> lk <br /> /iG�• / n ) <br /> Contractor Row S Gf/ /FJ lddress 07r�� W�LCC�'.r �l�_ License No. � '�Phone <br /> TYPE OF WELL/ .._ _ ANEW WELL; WELL_REPLACEMENT.G7 =DESTRUCTION,❑- <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTI)ER �� / <br /> DISTANCE TO NEAREST: SEPTIC TANK —,SEWER LINES '+_- DISPOSAL FLD..f P O LINE <br /> FOUNDATION _ /D� -(AGRICULTURE`WELL OTHER WELL 4 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL'`; PROBLEM AREAx{CONSTRUCTION SPECIFICATIONyS, <br /> ❑ Industrial ❑ Open Bottom ❑-Manteca-, 5:-.Dia: of Well Excavation 1 t Dia. of Well Casing <br /> ADomestic/Private )0 Gravel Pack 10 Tracy. =-Type of Casing Pym Specifications <br /> © Public ❑ Other ❑ Delta Depth�'of Grout Seal `1 Type of Grout ICS <br /> ❑ Irrigation 126pprox. Depth ❑ Eastern .t._�Surface Seal Installed,by <br /> Repair Work Done L� Type of Pump /7�i H.P. I f -•State Work Done_ <br /> Well Destruction ❑ Well Diameter t t Sealing'Material {top 50-')-,' <br /> R � . <br /> Depth 4 ' Filler Material (Belaw•50'1':' - JJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR''/ADDITION ❑ DESTRUCTION-r] (No septic system permitted if public sewer is <br /> s _ �; ,••� 1 available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other i <br /> Number of livinb units: Number of bedrooms. I', _A4 <br /> Character of soil to a depth of 3 feet: ------- Water table depth d <br /> SEPTIC TANK i ❑ Type/Mfg Capacity [ —No. Compartments <br /> PKG. TREATMENT PLT. ❑ [t � 1 Method of Disposal <br /> +� Distance to nearest _Well \ Foundation 1 Property Line <br /> G <br /> LEACHING LINE, ElNo. & Length of lines r r y� Total length/size <br /> .FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ~. SEEPAGE PITS O Depth ~ !Size4"-'..4��'-• °- � -:Number :. --. <br /> Y r :. <br /> SUMPS ❑ Distance tonearest• 'Well; Foundation Property Line <br /> DISPOSAL PONDS _. ❑ I <br /> I hereby certify thank:.`#Save prepared this application and that-the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatiorkrof the San Joaquin Local Health District., <br /> Home owner or licen40 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 inJL1ch 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 /> tionlaws of Califomie j r <br /> The applicant �}t f all re i d inspections: Complete drawing on reverse ide. <br /> Signed X ! $ � Title: A, - <br /> /� FOR DEPARTMENT USE ONLY <br /> —�G' <br /> ��1It Date 5 Application Accepted by •• ,� - <br /> i <br /> Pit or Grout Inspection by ! wt—e ,3- 5::9 Final Inspection by Date <br /> -� <br /> Additional Comments: . Al`rt-/ —�i �+® __ /+! �/ —C7 Ne P 1 �/� rn- ' "'� r'7 - <br /> t^D:Stk .466-6781 I❑i Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 <br /> r <br /> Applicant-Aeturn_all,.Oopies..to:_Environmental4WBtIth-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201Sr`ho ,k <br /> IFEE <br /> NFO AMOUNT DUE iAMOUNT REMITTED CASH RECEIVED ay DATE PERMIT'NO. <br /> + EH 13-24 fREV.Fiesi <br /> EH 14-28 <br /> k <br />