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BCCI/� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.; STOCKTON, CA Sd%A <br /> g_ Telephone (209) 486-6781 <br /> r O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate? a I 7z <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 /> Job Address _ff 5 C City,iq Cr4L� Lot Size <br /> ,;: J aC�-S. PM <br /> Owner's Name ?aldl-S dA- &S Address l CG_ �� 7 Y�Ct :i,�q�� Phone <br /> Contractor h Address ti-• L1Dti-� � _ oC]�2 T5 �i Phone <br /> 2 _ License N <br /> TYPE OF WELL/PUMP; — � NEW WELL - WELL­REPLACEMENT ❑ ----DESTHUGTION_❑--7--7 -m- <br /> PUMP INSTALLATION>X— SYSTEM REPAIR C7 OTHEP ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �C b '-� SEWER LINES DISPOSAL FLD.162, PROP. LINE <br /> FOUNDATION �� AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> yr _ <br /> ❑ Industrial Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> $C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing l Specifications <br /> i`I Public Cl Other fl Delta Depth of Grout Seal 7 Type Grout�nt z°+t�_. <br /> I I Irrigation c _'C2-Approx. Depth I I Eastern Surface Seal Installed b, n Y <br /> Repair Work Done L) Type.of Pump - H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other — <br /> Number of living units: Number of bedrooms m <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I_ <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Welt Foundation Property Line .� <br /> DISPOSAL PONDS Q �- <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 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 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X ra �A-a 4 n 4 J.�_ Title: e—ci, Data: <br /> FOR DEPARTMENT USE ONLY ! _X <br /> Application Accepted by _ _.. Date * " Area <br /> r , <br /> Pit or Grout Inspection Data Final Inspection by Date <br /> Additional Comments: d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH y RECEIVED BY DATE PERMIT'NO. <br /> r( r p ] <br /> r.EH 13-24 IREV.i/n 51 <br /> EH 14-26 r <br />