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' � r <br /> APPLICATION FOR PERMIT <br /> 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 /> (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 /> 4 Job Address _G dy 4-Ar- City�7 (I Lot Size �M <br /> ' � '.Ja 1 1 <br /> Owner's N _j7 <br /> ame Address Phone G <br /> rlev f G' <br /> Contractor's Name tj: <br /> License No. Phone t. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ei <br /> PUMP I STALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC ANK SEWER LINES DISPOSAL FLD. P 4 ^ Q <br /> FOUND TION AGRICULTURE WELL OTHER WELL PI S/~w <br /> tiF <br /> INTENDED USE TYPE F WELL PROBLEM AREA CONSTRUCTION SPEC IFICA -- <br /> ❑ Industrial r ❑ OpelBottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domestic/Private ❑ G11a I ck ❑ Tracy Type of Casing Spec ications <br /> ❑ Public ❑ Oth4 ❑ Delta Depth of Grout Seal Type of Grout" <br /> ❑ Irrigation _le ox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Typump H.P.`. State Work Done <br /> Well Destruction ❑ Weleter Sealing Material /top 50'1 <br /> DepFiller_Mlaterial (Below 50') <br /> —TYPE OF SEPTIC WORK: NSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic s4mit <br /> u lic e r is <br /> available wit .. <br /> Installation wlfeserve: ResidCommercial_.__— Other <br /> <. <br /> Number of living units: mber of bedroomsCharacter of soil to a depthet: Water table de th <br /> SEP YP g Capacity No. Compartm nts <br /> PKG TREATMENT PLT. ❑ osal ' <br /> A Distance to nearest: Well Fo indation P operty Line <br /> y� LEA MING LINE No. a Total len th/size t3� <br /> FIL R BED ❑ Distance to nearest: Well Fc undation I roperry Line <br /> SEE AGE PITS i%r Depth –2-,5r/ Size - " e <br /> SU PS _,,� ❑ Distance to nearest: `Well•. Fc ndation I roperty Lute <br /> Y <br /> DIS OSAL PONDS ❑ S <br /> I he by certify that I have prepared this application and that the work will a done in accordance w ry ordinances, state <br /> ule and regulations of the San Joaquin Local Health District. ' <br /> owner or licensed age ifies the following: "I certify t at in the performance of he work for which his permit is issued, I shall n <br /> y any person in such ner as to bec a subject to workman's com nsation laws of Californi ." Contractors hiri g or sub-contractin signatu <br /> cert as the following: "I ce that in the pe otmance of the work for whic this permit is issued,I sh 11-employ persons s bject to workman's ompen <br /> tion aws of California." <br /> n , <br /> The applicant must call for <br /> r all required ins erre side. / <br /> Sig d �' Title: D e:` <br /> I. FOR DEPARTMENT USE;bN Y elk <br /> � �Application Accept by to Area <br /> Pit r Grout Inspec n by Date Final In�SAc'o11Wy Date <br /> r 1 <br /> Comma f <br /> 1 �L 1 nteca` -7104 ❑ Tracy 835-6385-`' 1 <br /> ~AA a t- Antdl ices 1601 t <br /> �iL��� FEE CK � [ ` 7DA <br /> NF AMQUNT DUE MDUNT REMITTED CA H R ED BY PERMIT''ND. <br /> + EH 13-24 141EY.141931 � <br /> EH 1426 I''� <br />