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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :A601 E. HAZELTON AVE., STOCKTON, -CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES T 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. Q <br /> Job Address d �8 Q City (:A- Lot Size &t PM <br /> Owner's Name �[/T91�wAddress + PA-iv �r1626- 1 <br /> Phone IV <br /> Contracts QSei l�- +' 1 L !. .bL Address_L-11 - 4111 � b� ense No. d`�� Phone,� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKr <br /> isW SEWER LINES /S_� 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 Excavat'an Dia. ofWell Casing 160 <br /> ! <br /> Domestic/Private Gravel Pack 171Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - L <br /> I I Irrigation .2%`Approx. Depth I I Eastern Surface Seal lnstalled by en _ <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 CIO <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION i 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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: d nAu qr t Al depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity_.�l1ks, 4rpgr�entsy <br /> PKG. TREATMENT PLT. ❑ Method of rl�osal �J`+ <br /> -7 <br /> Distance to nearest: Well Foundation F [y �ine <br /> LEACHING LINE ❑ No. & Length of lines TR4}ylath/,�; <br /> FILTER BED ❑ Distance to nearest: Well Foundation —prig LIh� I- <br /> VICES _. <br /> SEEPAGE PITS i I Depth Sire Number <br /> SUMPS D Distance to nearest: , Well Foundation" Property Line <br /> DISPOSAL PONDS ❑ <br />- <br /> -"--1 hereby certify that-t-have-prepared'this application and that the work will be done in accordance wi$i Sarl 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 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 laws of California." <br /> The applicant must call"ailreed inspections. Complete drawing on reverse side. Q�f <br /> C / / ty C <br /> Signed X L.L. — Title: a - �0 Date: ! 9_F <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �� Area ®� <br /> Pit or Grout nspection by Date Final In action by Dat <br /> Additional Comments:Z +ry � � 7 a4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f �� �o� aWL"o <br /> ApplicaRe;urn all copies to: Environmental Health0 Permi ry es 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 /� <br /> BErfa�/r �'�.eadT��✓, �i�"'°+d�.I45G.�,d�o�� 1�yfS� <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> + EH17 <br /> 11-29 f r (a ll f L <br /> 3-21tREV.1/N51 <br /> EH ` 0 `fT 112 <br /> . <br /> s <br />