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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �. <br /> � r 1601 E. HAZELTON AVE., STOCKTON, CA ;i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-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. <br /> Job Address pF <br /> Q 3 a [3 077 W . i3RCADWi City +ackTbkot Size PM <br /> tty <br /> Owner's Name ED FPilR,K AVOKI Address Lp! 461 Phone <br /> Contractor <br /> Address i F License ho. 6 f _Phone1 6 <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> j ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 <br /> Ld Domestic/Private- ❑ Graver Pack ❑ Tracy Type of Casing Specifications <br /> xf;l Public ❑ Other F) Delta Depth of Grout Seal Type of Grout <br /> °i'I Irrigation _.-Approx. Depth l 1 Eastern Surface Seal Installed,by <br /> -ftep it Work Done ❑ Type of Pump H.P. State Work Done <br /> "Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material /Below 50') <br /> T7YPE OF SEPTIC WORK: NEW INSTAL--LATIOW4 I -REPAIRI:ADDITION {-I DESTRUCTION (No septic system permitted if public sewer is <br /> l available within 200 feet.) <br /> d Installation will serve: Residence Commercial— Other @ <br /> f `P <br /> Number of living units: Number of bedrooms s {. �$ <br /> *"''Character of soil to a depth of 3 feet: pth I <br /> Water table de <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f <br /> e PKG. TREATMENT PLT. ❑ ¢ i Method of Disposal <br /> Distance to nearest: Well .Foundation Property line <br /> f <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> �' <br /> FILTER BED ❑ Distance to nearest: We <br /> Foundation Property Line <br /> SEEPAGE PITS 11 depth Size}" Number <br /> SUMPS C Distance to nearest: Well gFoundation Property Line <br /> ,f-DISPOSAL PONOS ❑ r 'n t- ; <br /> I heiieby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules andregulations 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 nst call for all required inspections. Complete.drawing onreverseside. <br /> Signed Title: Date: �1 <br /> "i <br /> 013-DEPARTMENT USE ONLY <br /> !RFApplication Accepted by Date �J�-' Area <br /> Ir Pit,or Grout Inspection by Date Final Inspection by Date >Qa' <br /> Additional Comments: i ✓ -r L4'1 <br /> )C�IZ'Stk:.466 6781 ❑ Lodi 3621 ❑FManteca $23 7104 ❑ Tracy 835-6385 1 <br /> Applicant - Return all copies to: Environmental Healtkl?errT WServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> f „ <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH ECEIVED BY DATE PERMIT"NO. <br /> � � r <br /> :.EH 13-24111EV.siinsl 3_5 <br />