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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> v (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. Q, <br /> Job Address 2 7 fIr Q 4 44 tiC-ANO '`/�1n City CC.*4er•S Lot Size �d PM <br /> Owner's Name V d 1IV kLF7 A," Address S-41%l Phone S93 7v-L <br /> Contractor Address/00 Z?OX 7a c27License GPha <br /> TYPE OF WELL./PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.,LINE-7A. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L f <br /> . Dia. of Well Casing <br /> Domestic/Private I GFWebl Pack ❑ Tracy Type of Casing p V C ; Specifications <br /> I`l Public ❑ Other ~� R.Delta_ Depth of Grout Seal Type of Grout <br /> 11 Irrigation _-Approxi Depth l I Eastern`'Surtace.Sealanstalled 6yA/IrILC'�JIZ A <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ �\ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'.) \ <br /> i Depth Filler Material (Below 50') - <br /> { Vl <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> I T I <br /> available within 200 feet:/ <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms + <br /> Charecter,bf foil to a depth of 3 feett ° Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> " .1 I r <br /> -� Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ;--,ke A tyr_ Total length/size <br /> tt Ile -1 <br /> 'FILTER BED l.. - El Distance to nearest: .t Well'­— '—Foundation ""-""'"""Proparry,Une ` <br /> SEEPAGE'PFTS ('I Depth I t Size`, Number + <br /> SUMPS `J �. 0Distance to nearest: Welh, Foundation Property Line ' <br /> DISPOSAL PONDS ❑ <br /> I hereby certifythat 1 have prepared this application and thai'the work will.6e done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Heaith.District: , <br /> Home owner or licensed agent's signature certifies the following:", <br /> '1 ce�ifyFthat in tKe 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 work man'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 laws of California." k <br /> The applicant must call far all req fired inspections.,,Complete drawing on reverse side. <br /> Signed X fir Title: _( (A Date: <br /> 1 iFOR DEPART <br /> Application Accepted by � Date Area <br /> ry <br /> Pit or Grout Inspection by Date Z' -_ -Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 { ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> ..FEE.-, AMOUNT DLIE,_;,_ : AMOUNT.REMITTED . RECEIVED_BY„",,,,. ATE.__ . PERMIT'NO. <br /> INFO <br /> i �--y <br /> +.EH13-241REV.1/n5) + �/ <br /> EH 14 /J � <br /> 26 j ` �� O 4..-Ss�� _6&d <br />