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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601'*E:.,HAZE�T.ON'AVE�#STOCKTON, CA <br />Telephone (209) 466-6781 <br />P. <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />n. t (Complete in Triplicate) '> <br />e <br />OCT 13 111-104., <br />Application is hereby made to the![San Joaquin Local Health District for a permit to construct and/or install the work�oYi}ih db§Cr1tiedJTt s bp U aivibn is <br />made in compliance with San Joagwn County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules ars iegu�lat oils -of a San..�oaqutn <br />Local Health District. 1 �' { � <br />Flz ORA <br />JOU MUUMUU <br />Owner's Name `r r �r Qle6�✓ Address',, `-' E'6, Phone <br />t <br />N 1 �f `. <br />�� ` Phone � p 46 Z <br />Contractor's Name cense No / <br />TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP,INSTALLATION El SYSTEM REPAIR 0� OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS _ <br />INTENDED,L SE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑Industrial `"� ❑.Open Bottom `�O Ma"nteca Dia. of,Wall Excavation ---- Die: of Well Casing <br />WID'omestic/Private -10 Gravel Pack'❑ Tracy Type of Casing Specifications <br />LR blic Other ❑ Delta Depth of Grout El Seal Type of Grout <br />❑ Irrigation --Approx. De h 1:1Eastern Surf a Seal Installed by <br />/ <br />Repair Work Done [eType of Pump H. P. /7-1; f _ State Work Dane <br />Well Destruction ❑ Well Diameter Sealing Material {top 50') <br />Depth1 Filler Material {Below 50') <br />TYPE OF SEPTIC WORK: NEW <br />INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is <br />.I1. <br />i available within 200 feet.) <br />Installation will serve: Residence <br />_ Commercial _ Other <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth of'3 <br />feet: " - Water table depth <br />SEPTIC TANK ❑ TypelMfg <br />Capacity f No. Compartments <br />PKG. TREATMENT PLT. ❑ <br />� w t Method of Disposal <br />Distance <br />to nearest: Well Foundation Property Line <br />LEACHING LINE LJ 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 ElJI. T <br />I hereby certify that I have <br />rules and regulations of the <br />Home owner or licensed ag+ <br />employ any person in i <br />cartifies the follow' g: "I cel <br />tion laws of Cal' of nia. <br />pplicant u" <br />The al callilr <br />Signed <br />Application Accepted by <br />Pit or Grout Inspection by <br />Additional Comments: <br />�tk 466 6781 ❑ Lodi <br />A pllcant - Return all copies to <br />+ EH 13-24 (REV. 10183 <br />EH 1126 <br />I this application and that the work will be done in,accordance with San Joaquin county ordinances, state laws, and <br />aquin Local Health District. ' <br />Inature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br />as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature <br />in the performance of the work f ich this permit is issued, I shall employ persons subject to workman's compensa- <br />A <br />FOR <br />Date <br />on reverse <br />Date: /e /J !c+ s° <br />1 </ <br />IT USE ONLY <br />i Date �y V_av <br />x Area <br />Final Inspection by Date <br />369-3621 ❑ Manteca 823-7104 ❑ Tracy `835-6385 <br />Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE <br />INFO <br />AMOUNT <br />DUE <br />AMOUNT REMITTED <br />CK RECEIVED BY <br />CASH <br />DATE <br />PERMIT'N0. <br />