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� , . <br /> ,. <br /> APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., ,STOCKTON, CA <br /> Telephone (209) ffi-Ml <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 o ` i ` application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage of No.1862 for letioris of <br /> tie <br /> web/pump and the Ru1�Nltthe San Joaquin <br /> Local Health District. <br /> Job Address ^7 tyCity Lot Site 'f PM <br /> v <br /> Owner's Name Address V29 GQ+tl yO/� -. Phone <br /> Contractor 1c['i4Ie 140A lfS Address// !7 Cil f.� <br /> .,�.���,. (f27 Xi-��.�, Lice►�se No.��/��l�_@done <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ "",I)ESTRUCTION " <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3 <br /> *11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> ❑ DomestWPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Spac�t <br /> ❑ Public ❑ Other ❑ Delta Depth of' rout gbal Typeyosf <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Doyle <br /> Wall Destruction 0 Well Diameter Sealing Material(top 50 <br /> Depth Filler,Material(Below 501 <br /> TYPE OF SEPTIC WORIC NEW INSTALLATION b REPAiRIADDITION ❑ DESTRUCTION, (No septic system permitted if public sewer a <br /> available Vltflin 209'feet. <br /> lnstallatibn vl6 setae: Residence— Commercial— Other <br /> Number of livinf ttn :z Number of bedrooms <br /> Character of soil to-a depth of 3 feet: Water table depth "mss+ <br /> SEPTIC TANK G] Type/Mfg Capacity No..Compartments <br /> KG. TREATMENT PLT.❑ Method of Disposal U <br /> titance,to- MIST -Well r Property Line <br /> LEACHING LINE ❑ No.& Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation ­20- Property Line _ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS {] <br /> I hereby certify that I have prepared this eppr ation and that.the work w111 be done in accordance with San Joaquin`o lntybt ar date laws,and_ <br /> rulwand tilguiations of he San Joaquin Local`Health District, —_ <br /> Hoi4 owner or iicensiiid dm's signature certifn the following:,"I certify that in the <br /> rtlfy performance of the work for which this perltlii is issued> t shell not:.. <br /> employ any pawn in such manner as to become subject to work rlan's compensation laws of Cafifomia."Contractor's hag or sub-oohowft signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons sub t to workman's compensa- <br /> tion laws of California." <br /> The applicant at all for uired tions. Complete drawing on reverse sloe. <br /> XSigned Title: Rj9te: 'f $tv <br /> FOR DEPAR. ENT USE ONLY <br /> ApplicationAcceptedby Late �" '" v Area <br /> Pit or Grout Inspection by Date Final InspecticRt Date <br /> Additional Comments. _ <br /> El Stk 48&8781Lodi 369-3621 O:Mantaoaa' 023-7104 , d Tracy m54386 <br /> Applicant- Return all to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - FEE AMOUNT DUE AMOUNT REMITTED Tim RECEIVED BY DATE PERMIT'NO. <br /> INFO 4AW <br /> +EH 13-24(REV.I/es) <br /> EH 14-25 o b <br />