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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA :, <br /> Telephone (2091466-6781 L <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICo171plete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Heaith District for a permit to construct and/of 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. n _ <br /> Job Address Z6 �_,__I KA��-iZ-,L.G � AAq jt1G'fi y C-'c t I. Lot Size PM _ <br /> `7 ► -7 1 C. <br /> Owner's Namur ( =L_uZ S '� Address �-� '_�� � 1fJ <br /> ' Phone <br /> ci.Af�%- <br /> Contractor 1r�'r:f1lrM 5 _Address.21!&, IeLx License No. t.-' Phone =XI' <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT i DESTRUCTION L1 <br /> ______.. -. --------- PUMP INSTALLATION)<CLfI O-LAAT-SYSTEM REPAIR ❑ OTHER El <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 /> D D1 <br /> ustrial LI Open Bottom i_:, Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mestic/Private LI Gravel Pack L1 Tracy Type of Casing Specifications <br /> Public Ll Other Delta Depth of Grout Seal Type of Grout <br /> I I Irngation — Approx. Depth 1 ! Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump S!:Lh H.P. Z- 'KC- State Work Done l j <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 50') 9 , r <br /> Depth Filler Materia! (Below 50') -g- <br /> TYPE <br /> - f <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ! 1 REFAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer !s �/ <br /> available within 200 feet.} <br /> installation will serve: Residence_ Commercial: Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. [A Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE F1 No. & Length of lines Total length/size <br /> FILTER IJED ❑ Distance to nearest:' Well Foundation _ Property Line c <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS LI <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, I shall employ persons subject to workman's compensa- <br /> tion laws of CalifoE " <br /> The applic nt. 'J -call for equired inspections. Complete drawing on a rse sid <br /> Signed,* Title: <br /> Date: <br /> y R DEPARTM NT USE LY <br /> �/y� <br /> Applica n`A ed by 1I` '41-1 ~i Date l p� f / Area <br /> Pit or Grout Inspection by Date Final Inspection by /�P a�' Date ��_-,_ �� <br /> a <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D 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 95291 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV. <br /> EH 14-28 �b q U tj <br />