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APPLICATION FOR PERMIT ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :- 1601 E. HAZELTON AVE., STOCKTON, CA. <br /> Telephone (209) 466-6781 f <br /> 0•LL. <br /> I <br /> PERMIT EXPIRES f YEAR FROM DATE ISSUED `_ JUL 22 19$5 <br /> (Complete in Triplicate} <br /> .i ENV CLQ ra l: <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor .�y ��1ation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryle9tld� � dlatflsyd�an Joaquin <br /> l Local Health District. r.3rd' i' <br /> Job Address _, 9I[A `y i Lot ii7e PM <br /> Owner's Name ��_ LLd) Address LL q �• -77 <br /> - Phone <br /> Contractor _,__,__ Address Q License No. ��� Phone <br /> TYPE OF WELL/PUMP: V N E 7 WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK [1[s�--� SEWER LINES DISPOSAL FLD. Lf / ?ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL Q PITS/SUMPS <br /> j <br /> INTENDED-USE- TYPE OF WELL PROBLENi'AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Ne Gravel Pack Tracy Type of Casing__ )OV6 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. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> +, <br /> e=>_VA Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEW MOTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence, Commercial_ Other v <br /> Number of living units: Number of bedrooms _. <br /> I Character of soil to a depth of 3 feet: s Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ + Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C] No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> -1-hereby certify-that-l' have prepared'tFiis application and that the Work will be done in accordance with San Joaquin county ordinances, s, s'°"t`a#e lawsYand `+ <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 tis issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cal'ornia." <br /> The applic ust call for all re uir inspections. mplete drawing on r arse 'de. <br /> Signed Title: Date: <br /> i <br /> - FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ;7 41Area <br /> Pit or Grout Inspection b //'� 4 <br /> he Y Date ' Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 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 /> FEE <br /> INFO AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> �{�a` X04/ _ <br /> + EH 13-24 SREV,rie,l ►i11� 1 ^7��7� �S�Cyry� - <br /> EH 1428 f V� ! L 3 S - <br />