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Alit APPLICATION FOR PERMIT ► <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> {/ 1601 E. HAZELTON AVE., STOCKTON, CA , <br /> l �<l Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> C m fete in Triplicate) <br /> l o p P ) _ 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 Ordina/nom 9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District 5P-5 <br /> :yam <br /> Job Address r! v, eV_ <br /> �e�l 031,e <br /> t`epity Lot Size.OC #CQnfS __ PM <br /> Owner's Name � S Address l Phone <br /> Contractor �1�a�I 1,(c Address // . ���--r �`C, 'License Nod 7. � Phone�2_ '_1 Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLAT&N . SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES _!t=�`� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL &::)tpOTHER WELL-2-Ze-L PITS/SUMPS <br /> "'INTENDED USES—--TYPE--OF-WEL-L----PROBL-EM AREA�-CONSTRur.TION,.SPECIFICATIONS— <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> C�LeDpmestic/Private 4RCGravel Pack ❑ Tracy Type of Casing Specifications / <br /> F1 Public Cl Other 1--1 Delta Depth of Grout Seal / yqe Grout <br /> p��t7 <br /> I I Irrigation epth t I Eastern Surface Seal Installed by rk <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth i Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence��. Commercial— Other <br /> Number of living units: Number of bedrooms r F <br /> Character of soil to a depth of 3 feet: ° <br /> SEPTIC TANK ' ❑ Type/Mfg p Cay' <br /> PKG. TREATMENT PLT. ❑ j /r <br /> Distance to nearest: Well Foundati n <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundati <br /> SEEPAGE PITS i I Depth � Size r- <br /> SUMPS Ll Distance to nearest: Well Foundati <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be don(, li//�f/II`/ �� jws, and 4 <br /> -- rules-and-regulations-of the San-Joaquin Local-Health-Di§trict:­._ -—"�­ _4 - , J <br /> Home owner or licensed agent's signature certifies the following: "I certify that in tl shall not `i <br /> employ any person in such manner as to become subject to workman's compensatic signature <br /> certifies the following: "I certify that in the performance of the work for which this pe, ;_npensa- ° <br /> tion laws of California." fl <br /> The applica/nt�m�st call fofr�aJll�r quired inspe tions. Complete drawing on reverse$i <br /> Signed X (✓ e,f- Title: f 11 <br /> ; <br /> OR DEPARTMENT USE ONLY: _ <br /> Application Accepted by Date <br /> Pit r Grout spection by ��� Final Inspection by Date-, <br /> Additional Comments: ©� y <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ fracy 83!f&'45, 4_ k <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO, <br /> +-EH13-241REV.1/Ab) <br /> EH 14-26 l V <br /> /j� <br />