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APPLICATION FOR PERMIT , . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 (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 Ryles and Regulations of the San Joaquin <br /> Local Health District <br /> 7 vErJ r,.:�jl . ., <br /> Job Address � �. PEfLS,,�/.✓G r City' S7XA] Lot Size+ `%SO Tx1O0 pM t. <br /> Owner's Name Z A?,UGGJ_E S "Address 5 i1 Phone - <br /> Contractor F1,6!; D Af. LIJ"D Address 1WXLicense No. 9Y�CY7 b Phone S 397 <br /> TYPE OF WELL/PUMP: — NEW WELL-D­ -WELLREPLACEMENT'❑" '"mm"" ""DESTRUCTION-I] <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEL4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other N .._- _E]_Delta� Depth of Grout Seal Type of Grout <br /> ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> f Repair Work Done ❑ Type of Pump 1+� H.P. State Work Done C1111 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ; <br /> i` Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> r � <br /> Number of living units: Number-of bedrooms. 12 <br /> Character of soil to a depth of 3 feet: -!r" c1 Water table depth <br /> SEPTIC TANK EI Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE P-_`No. & Length of lines I�" 4A Total length/size <br /> FILTER BED ❑ Distance to nearest: Well /DD t Foundation ?.t7 'rte• Property-Line <br /> SEEPAGE PITS IE Depth f/7 size 1 7- - -Number <br /> SUMPS Distance to nearest: Well ' Foundation 2tJ Property Lina" <br /> r DISPOSAL PONDS ❑ <br /> } I hereby certify that I have prepared this-application and that tF�e,work will be done in-6tcordance 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,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,cofnpensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify-that'in-tho-Wormarlce of the Work-forwKidK-tKis"0d-rmit'is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California.- i r <br /> The applicant must-call for all,re iced inspections. C plete drawing on reverse side. <br /> SignedTitle- Date: <br /> r". FOR DEPARTMENT USE ONLY <br /> o Application Accepted by - - Date Area <br /> -.Pitvr Grout Inspection by`y - to 13 r91 Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 46"M1 ❑ Lodi 369-3621 ❑ Manteca 8217104 ❑ Tracy 5-6385 �p a•n <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. , t �� <br /> t <br /> • FEE= t-AMOUNT DUE .r AMOUNT-REMITTED. .SCK RECEIVED-BY"""----DATE""" r PERMIT NO.' <br /> INF GASH <br /> + EH 13-24(REV.!/65) <br /> EH 1428 t`"'" <br />