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r <br /> J APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCA! HEALTH DISTRICT ! <br /> .r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> ;I (Complete in Triplicate) 't <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 /> j <br /> Job Address LIQ �f "S f� s , <br /> r � � ' <br /> . Cit/y� � f�& Lot Size - PM <br /> Owner's Name off,a �C oAddress t' L t" ��11�=] �'f 2AJ Phone <br /> I f <br /> Contractor rug'—Address License No. 47 Phone k-1 g <br /> TYPE OF WELL/PUMP: rNEW WELL N--- WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 \_ PUMP INSTALLATION,&- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:kSEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> E <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation <br /> i ., Qia. of Well Casing <br /> LW6omestic/Private �ravel Pack ❑ Tracy Type of Casing_ z 1 7e r-4 Specifications <br /> ❑ Public ❑ Other �` L1 Delta Depth of Grout Seal — c, <br /> \, p a Type of Grout <br /> El Irrigation I ---Approx. Depth-, ❑ Eastern Surfac�Seal Installed by <br /> Repair Work pone ❑ Type of Pump �r r _ H.P. L%� , � .State Work Done <br /> Well Destructiori ❑ Well Diameter Sealing Material (top 50') <br /> a Depth Filler Material (Below 50') �^ <br /> . PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) (� <br /> Installation erne: Residence_ Commercial_ Other - I <br /> Number of living units: Number of bedrooms �(\ <br /> Character of sail to a depth of 3 a " 1 <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> d Distance to nearest: Well 'tion Property Line <br /> LEACHING LINE ❑ No. & Length of lines ��Totll a sizeFILTER BED ❑ Distance to nearest: Well FoundatProperty LI <br /> SEEPAGE PITS r ❑ Depth Size Number { <br /> SUMPS ❑ Distance to nearest: Well Foundation Property"Line <br /> DISPOSAL PONDS ❑ <br /> 44 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, ander <br /> 1 1 rules and regulations 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 <br /> '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 subcontracting signature <br /> certifies the following:"I certify that 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 ca I for all re wired inspections. Complete dr wing on reverse side. b` <br /> Signed r Title: `. : Date:i <br /> FOR YEPARTMENT USE ONLY 1 <br /> Application Accepted by Date ��.5 Area <br /> t <br /> Pit or Grout Inspection by at Final Ens n b _ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ &anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazatton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rEE <br /> —AMOUNT-DUERECEIVED'BY" —DAT "INFO - SR <br /> /� ¢ O " pERfiAIT'"NO=, <br /> + EH 1&24 IREY.t/e 5) `FY ClA `rl'V '' -} O'? 3 � �•"y •�•�~���� <br /> EH 1428 ii <br />