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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) • 4 <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 Z 174 K � eo, City 5 Lot Size PM ' <br /> Owner's Name Address Phone 7 `r7 7 <br /> ��1 <br /> Contractor mzo_,,Miw$__.44�gMddress RZAQ L[1 14 CD° License No. 6FF Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION 3a7&,QWZ_. STEM REPAIR ❑ OTHER ❑ <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. S State Work pone_lSsj� �h�«"ThU 0 <br /> z Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material f8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) #1 <br /> Installation will serve: Residence_ Commercial Other ( t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity} % Compartments . <br /> - `PKG. TREATMENT PLT. ❑ } Method of Disposal �s <br /> Distance to nearest: Well Foundation I Property Line <br /> LEACHING LINE ❑ No. & Length of lines V I Total length/size <br /> C r <br /> FILTER BED ❑ Distance to nearest: Well Foundation � Property Line i <br /> SEEPAGE PITS ❑ Depth Size l ` Number I <br /> r <br /> SUMPSE"""�"°"'❑""Distance"to nnea�esf —{N hF Foundation Property Line <br /> DISPOSAL PONDS ❑ # r <br /> I hereby certify that I have prepared this application and that the work will W dah inlaccordance with San-Joaquin county ordinances, state laws, and <br /> rules and regulations of the San JoaqufRhocal Health District. I <br /> Home owner or1icensed agent's sigrifii0re certifies the following: "I certify th�t in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner-as toltlecome subject to workman's comdonsationhaws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that iKthe performance of the work for whidh thisper rt is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California.'• 1 ' <br /> The applicant I r a requ�ctions. <br /> impletedrawjng on rave side. <br /> ii .r" <br /> Signed X, f Title: c� gate: <br /> _ <br /> F R DEPARTMENT USE ONLY l <br /> Application Accepted b r Date �h g�f Area <br /> Pit or Grout Inspection y "�Date Final Inspection by Date 2—z <br /> Additional Comments: _ •-- /?: �'[ _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 r b Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant- Return all copies to: Environmental Healtt Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> ? <br /> INFO AM60NT_Df1E" AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.1/B5) <br /> EH 1426 BSG /lt] <br /> -�"J <br />