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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />! ' 1 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> q1TTelephone (209) 466-6781 <br />! PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to i�he San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs 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 50-S5 l 1 V Cityao4mprLot Size6&0 X ty&o pM <br /> dp <br /> Owner's Name � .t1 Address , el Do, Phone`a`r?`7/ d" 01? <br /> � f * f'I 1 <br /> Contractor I AddressOil 7 License No.32egQ Phone & �S�,� <br /> TYPE OF WELL/PUMP: �i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE # <br /> FOUNDATION AGRICULTURE WELLL —OTHER-•WELL'T--- ,PITS/•SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial - —E, <br /> Open-Bottom ❑ Manteca Dia. of-Well-Excavation _Dia. of.WeEI,Casing <br /> Q Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications <br /> f'l PublicCl O`t er !1 F Delta Depth of Grout Seal Type of Grout s _ <br /> I I Irrigation �I-Approx-[Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type <br /> of Pump, H.P. State Work Done_ <br /> Well Destruction Q Well'Diameter ' Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') 6 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is 1N' <br /> / available within 200 feet.I <br /> Installation will serve: Res�idl�e��nce Commercial_ Other <br /> Number of living units: f II: Number of ooms <br /> Character of soil to a depth of 3 feet: Water table depot / lu,(" <br /> SEPTIC TANK P Tiype/Mfg Capacity_(400 _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Illi <br /> Distance to nearest: Well %0 Foundation /0 Property Line_i <br /> y1-+ r <br /> i f� <br /> LEACHING LINE,- No. & Length of lines Total length/size I <br /> i <br /> FILTER BED ❑ Distance to_nearest: Well Foundations Property Line_.. <br /> SEEPAGE PITS-- I+i--Dlepth - r _Size Number <br /> SUMPS., i, , <br /> L7 _Distance to nearest: Foundation `.(_property.-Line_ <br /> DISPOSAL PONDS ❑ �'• •-- <br /> I hereby certity`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 and regulations<of_the_Sart-Joaquin-Local Health District. <br /> Home owner or licensed agent'sksignature-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 maAdi as to'become subject to%workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the followin <br /> gt <br /> """i certify i'hat`in-the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California. <br /> The applicant mus II for all rell ed jiftpections. Complete drawing'on rev se side. <br /> Signed X II 4 _ Title_ Date: <br /> 3 <br /> If�. <br /> r` 7� <br /> up "` FOR DEP_ARTMENT•USE ONLY <br /> Application Accepted byDate <br /> 4l, Area <br /> Zor Grout Inspection by bated Final Inspection by Date L" <br /> Additional Comments: I� <br /> ❑ Stk 466-6781 ❑ Lodi I i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to:i Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNTTED T DUE AMOUNT REMICK CASH RECEIVED BY DATE PERMIT-NO. <br /> EH 3 24 � yy <br /> + EH 14-291REV.liH51 � I /r� <br /> I! 6 <br />