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11 APPLICATION FOR PERMIT s <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA RE- C E I V E D <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUE[) AUG <br /> ' I I <br /> {Complete in Triplicate} ENVIRONW <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the wo JA P1NrA� HEALTH <br /> application <br /> p ' <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 lot wi ll/pump and the Rules Reg�l�at ones o�the SanlJoaquin <br /> Local Health District. I <br /> Job Address 1 <br /> City Lot Size PM <br /> Owner's Nam Address <br /> °i Ph n 3"70 <br /> G33(:;' Oreuee flc? Pretrse,,zel5665 {'11 <br /> Contractor ill All ��*`'i 1 <br /> TYPE OF W L/PUMP; 111fLicense No. ^Phon� -S7/,Z, t <br /> NEW WELL ❑ ELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK11 <br /> OTHER ❑ <br /> SEWER LINES � DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS PETS/SUMPS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_/ ;� 1'� <br /> C! Domestic/Private ❑ Gravel Pack �— Dia. of Well Casing is <br /> 1�Tracy Type of casings(' O �/� n <br /> I'1 Public r OtherAA p _p 6O Specifications <br /> txCD/ ❑ Delta Depth of Grout Sea] L Ill S xgMr�+--k <br /> I I IrniJation 7,5.} �APril Depth I I Eastern 7YPe of Grout <br /> Repair Work Done U 7 Surface Sea! Installed by f�j o.J <br /> Type of Pump -�l0fk H.P. A2State Work Done <br /> Well Destruction ❑ Well Diameter �� "� <br /> �, �-r+�.� Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 -f-2- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AEPAIRIADDITION I 1 DESTRUCTED I 1 (No septictern w <br /> available within 200 leen l ed it putaht sewer is <br /> Installation will serve: Residence_'� Commercial— Other ` <br /> Number of livin units: <br /> 9 Number of bedrooms U) � <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ElType/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity. No, Compartments <br /> Method of Disposal III G <br /> Distance to nearest: Well Foundation <br /> ;1 Property Line <br /> r <br /> LEACHING LINE ❑ No. 8 Leriid1h of lines <br /> FILTER BEDi Total length/size it <br /> ❑ Distance to nearest: Well Foundation �r <br /> I Property Line <br /> SEEPAGE PiTS I I Depth I Size <br /> Number It <br /> SUMPS <br /> Ll Distance toinearest: Welt Foundation <br /> DISPOSAL PONOS [7) Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinarices, 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 certify that in the performance 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 /> tion taws of C ia." I <br /> The applic t m t tall far 11 r aired ' s ctions. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date; 3 <br /> FOR DEP TM T E ONLY <br /> Applic <br /> � Ar <br /> �` � <br /> Pit or Grout Inspection by _C� Date l k <br /> Data ` Final Inspection by <br /> Additional Comments: DateI'` } <br /> ❑ S4116-67Bi ❑ Lodi 369-36210 Manteca 823-7104 ❑ Tracy -6385 <br /> Applicant - Return all copies to: 835Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 1 <br /> FEE AMOUNT DUE AMOUNT RfMITTEp <br /> INFO SH RECEIVED BYEDATE <br /> PERMIT Np. <br /> • EH 19-24 INEV. <br /> 1C1Ct <br />