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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> ' (Complete in Triplicate) <br /> Application is hereby made to.. he 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 SandJoaquin 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. I� s <br /> �� ! City Lot Size Is�Cr PM ' <br /> Job Address pp <br /> + J Address S � /�ix�.0 Phone <br /> Owner's Name -- <br /> Contractor I Address,1Ae4Xo— License No. 2�Lo5 721 Phone .J <br /> TYPE OF WELL/PUMP: III t, j NEW WELL ❑ WELL REPLACEMENT iJ DESTRUCTION ❑ ` <br /> T <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 71OTHER EI <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 01 rdustrial 0:Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑,bomestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications (� <br /> l`I Public 1 1711 Other, F1 -Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation d :Approx. Depth I I Eastern � .urface Seal Installed by <br /> Repair Work dobe 12 Type of Pump H.P. 1�� State Work Done <br /> l Well Destruction ❑ Well Diameter Sealing wlaterial'It�op 50'1 <br /> r Depth Filler Material {Below 501 " <br /> k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIAD[:5!(TION tor DESTRUCTION I I (No septic system permitted if public sewer is <br /> ` available within 200 feet.) <br /> r 1 stallation will serve: Residence— Commercial COther <br /> Numbef of living units: Number o rooms <br /> a .F: <br /> Character of soil to a depth of.3,feet: ` ' Water table depth <br /> SEPTIC TANK Type/Mfg C�n9 �� k�+ Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ I may,,, ,] Method of <br /> Disposal <br /> Distance to neares We11 el r Foundation .__— Property.Line y <br /> a r' \ <br /> . I S— <br /> LEACHINGLINE­. ize! lh/ 3 <br /> f <br /> FILTER BED ❑ Qistane to near We11 Foundation 5 Property Line ! <br /> SEEPAGE PITS l4 R�epth .2 I ize �!;y' U Number_ <br /> I t �� fi` - f <br /> F SUMPS Ll. 'Distance to nearest: We I�l 5�✓_. Foundation�o Property Line <br /> F \ <br /> DISPOSAL PONDS ❑ ,. e- <br /> I hereby certify that I have prepared this application and that tl e work will be done inaccordance6th San Joaquin county ordinances state laws, and <br /> rules and regulations of the San Joaquin Local Health District. t <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, I shall not <br /> em�loy any person in such rrianner 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." F d <br /> The applicaW must call for all equired inspections. Complete drawing o reverse side. <br /> w <br /> Sig ed X !i' Title: %rI �XC ' Date: <br /> _1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -.-fii `-Date r Area�l <br /> r Grout Inspection by q1 �D e F al �spon by - Date r <br /> + Additional Comments: <br /> ❑ Stk-466-678.1 - ---19-both-�621—B—Manteca--823-7tO4—ElTracy""-835-6M <br /> Applicant - Return all copiai.to: Environmental Health Permit/Services 1601 E. Hazelton'Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED AK H RECEEi BY DATE PERM VNO. <br /> INFO <br /> +.EH13-241REV.1/k15Y 'V !} t 0 <br /> EH 14-28' (/ !/ - <br />