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APPLICATION FOR PERMIT <br /> .11-4 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. <br /> ter` <br /> t <br /> Job Address �/° oseM i Ave- City Lot Size /�r 26`PM <br /> Owner's Name ��� I 111 � Phone <br /> AV <br /> � , <br /> Contractor1/Y1 Address �Y��N"J AVII License No.� '2V1 33—Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ " WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ f SYSTEM REPAIR 71 OTHER C] <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 fiPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial LJ Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> { <br /> 1-1 Public ❑ Other •, HCl Delta tet--Depth-of--Grout Seal Type of Grout <br /> I 1 Irrigation _._ApproxeDepth_ l I Eastern i Surface Seal Installed by-'^^'-• <br /> Repair Work Done ❑ Type of Pump 5 �^H.P. t'State Wofk Done <br /> Well Destruction ID Well Diameter Sealing Material (top.50') <br /> Depth Filler Material (Belo 50')_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION- -•-DESTRUCTION-i-I-Wo septic system permitted if public sewer is i <br /> I \ i available within 200 feet.) i <br /> Installation will serve: Residence-V—/ Commercial_ Other <br /> Number of living units: _� Number of WToms <br /> Character of soil to a depth of 3 feet: N " Water table depth' ; <br /> SEPTIC TANKS ❑ Type/Mfg Capacity , No. Compartments y <br /> PKG. TREATMENT PLT. D _ y, Method of Disposal } 4 <br /> Distance to nearest: Well Foundation Property Line t # <br /> e i y t <br /> LEACHING LINE ❑ No. & Length of tines i Total length/size <br /> FILTER BED i ❑ Distance to nearest: Wel1i Foundation Property Line <br /> f <br /> SEEPAGE PITS I'1 Depth Size Number r' ) <br /> l �. <br /> SUMPS L�f Distance toQnearest: 4 Well Foundation 10 Property Line <br /> DISPOSAL PONDS LIDO > U fr'] _?o ST A(le 'rSte ©au 1 Aekc- JACOJLDkA <br /> I hereby certify that I have prepared this apptication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. i <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 ormance 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 applicantnaughL call for all r ylirea ins ctions. Complete drawing on reverse-side. <br /> Signed Title: C /e-a — _ Date: a�• �� <br /> 4 <br /> F DEPARTMENT USE ONLY , <br /> Application Accepted by Date A_re'a <br /> Pit or Grout Inspection by Date Final Inspecti by Date_ 1 <br /> r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 f \ <br /> —Qgplicant,,7_Return-all copies.to:-Environmental Health,Permit/-Services.1601-rE..Hazelton Ave.,-R.O.-Box 2009;`Stk., CA-95201. <br /> I <br /> r <br /> FEEMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. <br /> .INFO <br /> + EH13-24(RE <br /> V. /a 51 <br /> y <br /> EH 14-26 1 <br />