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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT4- <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 4 <br /> PERMIT EXPIRES.1 YEAR FROM DATE ISSUED, T <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 Ae Zwo City e2Z�WMZd Lot Size ISG. <br /> Owner's Name 40411VNIZ2 Address .0 )A c5 2Z <br /> Contractor's Namwo-,O)-,Z;�dz PUL;u x.- License No. &/oo Phone <br /> TYPE OF WELL/PUMP: NEW WELL (g. WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TAN' 490cllf- SEWER LINES 100A)6 DISPOSAL FLD.-tkJ-XJ.. PROP. LINE S�OO .'. <br /> FOUNDATION AGRICULTURE WELL-t-b0—'OTHER WELL-�2�41,v PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ­7- <br /> Ll Industrial LJ Open Bottom Ll Manteca Dia. of Well Ex�c avation Z biai:,of Well Casing b <br /> tl Domestic/Private Gravel Pack Ll Tracy Type of Casing Speci�ications <br /> El Public 0 Other i El Delta Depth of Grout Seal Type of Gr`outL2e1)7nA)1TC_ <br /> D Irrigation Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pum" H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sea_!ing Material (top 501 <br /> Depth - 4- Filler Material I Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system,permitted if publ' sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence FAA Commercial— Other <br /> Number of living unitsA— Number of bedrooms <br /> Character of soil to a depth-of 3 feet- Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity-- No. Compartments <br /> PKG. TREATMENT PLT, C t 4 Method of Disposal <br /> Distance to nearest. Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER RED C1 Distance to nearest: W611 Foundation Propdrty Line <br /> SEEPAGE PITS C Depth Size Number <br /> Ut <br /> SUMPS t El Distance to nearest: Well Foundation Property Line V <br /> DISPOSAL PONDS C is <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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certiff'that ittheperformance 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 /> i tion <br /> orkman Bcompensa- <br /> tion laws of California," <br /> The applicapm�t all for all required i C pl , drawing on reverse side. <br /> X=;Z ::��spe�cvons. �om , . Date: <br /> Signed itle: <br /> '�4 OR DEPARTMENT USE ONLY <br /> Application Accepted by Date A Area 0/' <br /> o,- <br /> Pit or Grout Inspectiorty ;2� Date t-v�/b'4U Final Inspection by Date iLd--k11yf <br /> Lefl > I-fiv-f L , <br /> Additional Comment= loreyh <br /> d <br /> 0 Stk 466-6781 10 Lodi 369-3621 '-D'Mdnteca 823-7104 0 Tracy 835-6385 <br /> fl Applicant- Return all copies to: Environmental Health Permit/Services 160I E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> A <br /> 8311 FEE AMOUNT DUE 'AMOUNT REMn7E.D CK It RECEIVED.,BY DATE PERMIT"NO <br /> I " <br /> NFO CASH, � <br /> LA,) <br /> + EH 13-24(REV.101 <br /> EH W26 <br />