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3 <br /> ✓�,� APPLICATIONS FOR PERMIT <br /> J SAN JOAQUIN LOCAL HEALTH DISTRICTW� � <br /> 1601 E. HAZELTON 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 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 4 Ept 166 City )JP6 '"' Lot Size PM i <br /> Vv <br /> Owner's Name Q �I dress �® � � _ Phone - <br /> License No. F t�"� V va <br /> Contractor's NameZ4 <br /> � _ Phone `' V <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 6n`V <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 SPECIFI .TV /f le <br /> '❑ Industrial - ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well.Casing <br /> E] Domestic/Private ❑ Gravel Pack ❑ Tracy 'N Type'of Casing 12,25 10 �+'�t - Specifications AM—La ' <br /> ❑ Public. ❑ Other ❑ Delta ` Depth of Grout Seal Type of Grou * <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump - .H.P. State Work-Done <br /> r_ <br /> _ Well Destruction _ -E-1Well Diameter" � d _Sealing Material_(top.50') ' <br /> Depth Filler Material (Below 501 r <br /> T PE OF SE WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ` Installation will serve: Residence_ Commercial_ Other •._ 5 ,, <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a`depth'of-3-feetr Water table depth I <br /> i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments j <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 r=El—Distance=to nearest: Well Foundation Property Line <br /> SEEPAGELPPITS ❑ Depth Size Number <br /> SUMPS r ❑ Distance to nearest: Well Foundation Property Line - <br /> DISPOSAL*PONDS ❑ . <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 eras-to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I c ify th in the rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Calif rnia." �' <br /> The applica st cal or r 1, d i spa do C' mplete drawing on r r e. [ <br /> / - 11 <br /> Signed +�' Title: Date:- <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Date 4 Area 6 <br /> 6-& - 2��' roh�'.Ivrr:.Jw�j/ de�h-� I7T/4,{ <br /> Pit or Grout Inspection by Date Final Ins ect' b ateC.-f k�— C�, C 112 '' / C&V< yVel,j ofet41v� , rev 1- /-o+ �>, . <br /> Additional Comments: 7 r ✓ �� 1 <br /> ❑ 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 /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH13-24(REV.10/83) <br /> EH 14-26 s <br />