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-�" - APPLICATIOfJ FOR=PERMIT <br /> h SAN JOAQUIN LOCAL HEALTH DISTRICT R <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (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 t City 2Fo ,,_Ifot Sizel�.0 PM <br /> Owner's!Name�/`?e K`{-/7 Address �� � e Phone 3 — <br /> Contrractor's Name CC G.�7. kaLicenseN .; :2 '2 Phone <br /> TYPE,OF WELL/PUMP: ANEW WELL❑ WELL REPLACEMENT DESTRUCTION <br /> a PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC T—ANk-,-&Q SEWER LINES DISPOSAL FLD. PROP. LINE ` k <br /> FOUNDATION ' , AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 ' <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open-Bottom ❑ Manteca Dia.,of Well Excavation Dia. of Well Casing <br /> Q DomesticlPrlvate• ,Gravel'Pack ❑ Tracy 4 . Type of Casing t' Specifications- .. <br /> ❑ Public .. �O-Other# ❑ Delta' _tea Depth of Grout Seal 5-,J ' pe of Grout de'n <br /> ❑ Irrigation ��pprox. Depth ❑ Ed,tern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump !S H.P. _ State Work Done �rA- ,vzZL <br /> Well Destruction 1'1f Well Diameter_ Sealing Material Itop 501 + P <br /> I Depth ,f0[7 ` Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.! t <br /> Installation will serve: Residence Commercial Other <br /> Number of living units._-=_ Number of•bedrooms <br /> Character of soil to a depth of 3 feet: "" Jk Water table depth <br /> SEPTIC TANK 1: Type/Mfg ' .r�'-., Capacity No. Compartments <br /> PKG YIREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTERi BED ❑ Distance to nearest: Well "Foundation Property Line <br /> � i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby It"ertif y that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i <br /> rules'anda egulations 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 lawsof California." <br />. .f <br /> The a: is ust c or all required i tions. femplete drawing on re side. <br /> Signed°, ^ Title: . r19 Date: S <br /> F <br /> :FOR.DEPARTMENT,USE ONLY { <br /> Application Accepted f Date f Area <br /> PitGrout specti y Date 2� Final Inspection bytr _ <br /> 4 . 0461� <br /> 6 44 <br /> Additional Comments: — <br /> a•,❑ Stk� 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8396385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601'E:Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 <br /> F' AMOUNT DUES OUNT R�ITTEDCASH ECEISCK RVED BYs' TDATE-'I "� PERMIT"NO. l <br /> INFO <br /> +EH 13-24 IREV 101831 <br /> EH 1426 <br />