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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT 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 a compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 22601 E. Flood 'Rd • City <br /> Lirideri Lot Size PM <br /> Job Address <br /> Duncan Rd. Phone <br /> Owner's Name Jim L�cfor� o Address <br /> 155 N. <br /> mac, P. 0. Box 64,UrLd%ge Ivo. 377923 Phone 887-3554 <br /> Contractor <br /> ]Purvi D�1��or�ddr ' {DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NEW WELL :9 WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION 71 DISPOSAL <br /> REPAIR LJ OTHER 171 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dial. of Well Casing <br /> Dia. of Well Excavation 16 <br /> ❑ Industrial fg Open Bottom ❑ Manteca Specifications 31.6 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> .� Delta Depth of Grout Seal Type of Grout <br /> * Public f 1 Other 71 - <br /> N Irrigation �.Approx_Depth,M..-L.1_Eastern._„�.—.- <br /> Surface.Sea1_lnstalled..by- ;' j <br /> State Work Done <br /> H P <br /> Repair Work Done Ll Type of Pump ` <br /> Sealing Material (top 50'i � �V <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material IBeiow 501 <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIRlADQITION l I QESTRUCTION I I availableseptic <br /> wit in 200 feet.) if public sewe <br /> r is <br /> Installation will serve: Residence_ Commercial— Other 1 <br /> Number of living units: Number of bedrooms ' <br /> Water1able depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity r No. Compartments <br /> _ <br /> SEPTIC TANK_. . -.❑ Type/Mfg _„--�--.,lNethod of isposal — <br /> t PKG. TREATMENT PLT. ❑ Property Line <br /> k Distance to nearest: Well Foundation v <br /> i <br /> Totallengthlsze <br /> LEACHING LINE Li <br /> 1 No. & Length of lines PropertyLine <br /> FILTER BED ❑ Distance to nearest: Size Welt Foundation <br /> i <br /> Number <br /> SEEPAGE PITS I t Depth \( <br /> SUMPS L1 Distance to nearest: Well <br /> Foundation Property Line rJw <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> # Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> r <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 subject to workman's compansa <br /> tion laws jof California."The applit must call.for II a uir dinspections. Complete drawing on reverse side. +Date: <br /> Y Signed X <br /> FOR DEPARTMENT USE ONLY <br /> - Date Area <br /> Application Accepted by ` <br /> Date <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> CK RECEIVED BY DATE PERMIT NO. <br /> r IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24(REV.1/8 5f r <br /> EH 14-28 <br />