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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ✓PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> 1<,pix + {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 /> Local Health District. <br /> PA <br /> Job Addree n �[! City Lot Size PM Z)KK 7r <br /> 3 <br /> Owner's Name IQAI A <br /> sddress -i `N`' � l�z'�— Phone. � �� <br /> Contractor's Name t R"License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION-N SYSTEM REPAIR ❑+- OTHER Elr <br /> DISTANCE TO NEAREST:_SEPTIC TANK 7py FF SEWER LINES (DISPOSAL FIDAMI- Q PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL^ PITS/ US MPS t52_0 <br /> INTENDED USE TYPE OF WELL `PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial jk9pen Bottom }❑-Manteca-� Dia, of Well Excavation (_ Dia. of Wall Casing <br /> ,WDomestic/Private ❑ Gravel Pack LJ Tracy -� � Type of Casing Specifications <br /> 1SLdw I t <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ¢Q <br /> ❑ Irrigation -1-Approx. Depth ❑ Eastern S rface Seal Installed by �` F <br /> Repair Work Done F] Type of Pump CA �� `�H.P. - State Work Done I <br /> Well Destruction ❑ Will Diameter t ea ng Material {top 501 <br /> Depth l �' _Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/ADDITION ❑ DESTRUCTION ❑"(No septic,system permitted If public sewer is <br /> ► available within 200 feet.) <br /> Installation will serve: Residence_ Commercials''�- Other <br /> Number of living units: - Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK r❑ . Type/Mfg �� Capacity - No. Compartments <br /> PKG. TREATMENT PLT © 171Method of Disposal <br /> k Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines , j Total length/size # <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line } <br /> + <br /> SEEPAGE PITS ❑ Depth Size Number �3- <br /> SUMPS ❑ Distance to nearest: Well Foundation Property-Line 4 <br /> DISPOSAL PONDS ❑ b z <br /> I hereby certify that I have prepared this application 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. <br /> Home owner or licensed agents 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 in such 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 subjectto workman's compensa- <br /> tion laws of California." 1 t l� <br /> The applicant rpupj call for all required inspec'ons. Complete drawing on reverse side. 1, <br /> Signed X Title: 4&e Date: l <br /> F A NT USE ONLY <br /> Application Accepted by Date 7 3Area <br /> Pit or Grout Ins F' al Inspection by Date ILqv-TI7 <br /> Additional Com e � � <br /> ❑ Stk 466-6761 ❑ Lodi 369-362. ❑ Manteca 823-7104 ❑ Tracy 835-6385 T <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> -7 <br /> +EH13-24(R1V.10/83) •4 ,�/¢ <br />„y„y,ry EH 142$ v <br />