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APPLICATION.FOR PERMIT <br /> O SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I Y+ (Complete in.Triplicate) <br /> i <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 ^Q City Lot Sized"OISE --PM <br /> Owner's Name 'Address �o�x�-�t� JA T Phone�� a 3 3 <br /> Contract r 1.4 Address '}6 -� License No3R4 12- Phone.Je -sms <br /> TYPE OF WELL/PUMP: 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 /> s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation * Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �'� Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth�f Grout Seal P Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work D e_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top/50') t <br /> Depth Fil rial (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONQ—FI1ZNLR/AD­D_1nPN E DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve: Residence Commercial_ Other I <br /> Number of'living units: Number of bedroo }. 173- <br /> Character of o•tl o a�h of 3-feet) ""' Water table depth liwk / <br /> ,SEPTIC TANK ❑ Type/Mfg{ f <br /> y Capacity No:Compartments. <br /> TREATMENT PLT. ❑ s Method of Disposal <br /> i Distance to nearest: Well Foundation- Property Line <br /> LEACHING LINE 0-- No. & Length of lines / # 'yam : ,__ Total lengthlsize fl Z <br /> • ;.y t r <br /> FILTER BED ❑ Distance to nearest: Well Fvundatt n ?Property Line <br /> SEEPAGE PITS Depth Size _ �� Number <br /> SUMPS ❑ .Distance to nearest:. Well Foundation Property Line - - <br /> DISPOSAL PONDS ❑ <br /> i hereby 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 /> tules and regulations of the San Joaquin Local Health District <br /> Homeowner 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 ahy 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." t <br /> The appli,an I st call for aired inspections. Complete drawing on reverse side. <br /> i � <br /> Signed Title: _ x1-L Date: -2-2--3—k <br /> " <br /> l FOR DEPARTMENT USE ONLY + <br /> Application Accepted by ' " ^ t' `�' - {Date Area :0 <br /> Pit or Grout Inspection by t �/r Date' Fin I Inspection by Dati; <br /> r t <br /> Additional Comments: <br /> Stk 466-6781 (`<Lodl 369-3621 ❑ Manteca 823-7104 .❑ Tracy 835-6385 <br /> Applicant- Return all copie -to: Environmental Health Permit/Services 1601 E. Hazelton Ave—P.O.cBox 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT NO. <br /> v(+ EH 13-24(REV.r H511'166 <br /> -r �1 . <br /> EH 14-28 o�_a <br /> i L <br />