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APPLICATION-FOR PERMIT <br /> SAN JOAQ1UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.TON AVE.—,STOCKTON, CA <br /> _Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED . <br /> - <br /> (Complete in iTriplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de;cribed. Thi's"application is <br /> .made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulation's of'the San Joaquin <br /> Local Health District. <br /> x <br /> Job Address / Z&O 04.Akd-QA City 4l ", Lot Size PM <br /> Owner's Name S-0—A Address 176?, me_9 A,/ Phone <br /> ;L.� C11 Address RQ.-&0% 7�T <br /> Contract License No. oZgo��. Phone <br /> TYPE OF WELL/PUMP: <br /> NEW WELL 0 WELL REPLACEMENT El DESTRUCTION D <br /> PUMP INSTALLATION E SYSTEMREPAIRE) OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINESvr DISPOSAL FLD._ PROP, LINE <br /> I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Open Bo Manteca 0 Industrial Bottom 0 Ma Dia. of Well Excavaticiii"-, Dia. of Well Casing <br /> ID Domestic/Private 0 Gravel Pack LJ Tracy Type of Casing— r Specifications <br /> L] Public 0 Other E] Delta Depth of Grout Seal - c,;,^ Type of Grout <br /> 1-1Irrigation --Approx. Depth Ll Eastern Surface Seal.Installed by <br /> :Repair Work Done EJ Type of Pump H,P. 'State Wo-rk Done <br /> Well Destruction , El Well Diameter Sealing Material (top50'1 <br /> Depth ­Q11er Material (Below 501 <br /> JTYPE OF SEPTIC.WORK.- NEW INSTALLATION 0 (IPA�IADDITION (24"DESTRUCTION CIANo septic system permitted if public sewer is <br /> 11 - / available within 200 feet,( <br /> i Installation will serge: Residence 1:1 Commercial— Other <br /> Number of living units:' -:I— Number of bedrooms <br /> Character of soil to a depth of 3 feet:. <br /> 'SEPTIC TANK Type/Mfg Capacity Water table depth <br /> � O� <br /> Ll No. &,partments <br /> ,PKG. TREATMENT PLT. I-] / U <br /> Method of Disposal <br /> Distance to nearest--Well— Foundation <br /> Property Line, <br /> LEACHING LINE No. & Length'of lines Total len9ih/,sizefq0 X <br /> FILTER BED atio <br /> E] Distance to nearest: well 6-0 Found n P?operty'Line <br /> SEEPAGE PITS Ue Depth 67 <br /> Number <br /> 1W or <br /> SUMPS 0 Distance to nearest- ZWe!E� ,_Founclation 10 Property Line <br /> L <br /> DISP SAPONDS D <br /> 'I hereby certify that I have prepared this application lication and~fiat the Work will be done :6 accordance with San Joaquin county ordinances, state laws, and <br /> rulei'-and regulations of the San Jqaqgi�n.Local Health District. <br /> Home owner or licensed agent's sig(hature certifies the following: "I certify that in the perform'ance 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°6rcalifornia.­Contractor's hiring or sub-contracting signature <br /> certifies thetolIQwir)g:._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 California.-, <br /> The appli 11 for drawing on reverse side. <br /> Signed "VA) I <br /> Title: Date: Q a�pAj VD— <br /> FUR-DEPARTMENT 7USE ONLY <br /> Application'Accepted by <br /> 7PDate Area <br /> 4 it Y. <br /> r Grout Inspection by <br /> Date - inal Inspection by <br /> Additional Comments: <br /> 0 Stk 466-6781 D Lodi .369-3621 0 Manteca 823-7104 0 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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED By <br /> CASH DATE PERMiT'NO, <br /> + EH 13-24(REV <br /> + 0 <br /> EN 14-26 -7o-0o to_ <br /> A10 Ph-3 o <br /> U - <br />