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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Job Address Rho o Citye Loi Size PM <br /> [� r <br /> Owner's Name 6RA(al\ ---- Address SAft Phone I lc^ 29 ZSCI <br /> Contractor L#4V ZiL'e— Address 15 -&Tro-J AVS_ License No. QV-31_j7 Phone G S_1'salf <br /> TYPE OF WELL/PUMP: NEW WELL 171 WELL REPLACEMENT ❑ T DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bott6rn ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack y y❑ Tracy Type of Casing Specifications <br /> r <br /> [-I Public t ❑ Other ��► ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _-.Approx.:Depth l I Eastern Surface Seal Installed by q <br /> Repair Work Done ❑ Type of Pump k r f H.P. . State Work Done <br /> Well Destruction i❑ Well Diameter �' Sealing Material (top 501 , �J <br /> ' Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION FA REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:k,Residence ' Commercial T Other ` <br /> s Number of living units: - r Number of bed\roopms +f <br /> r A� Y 11�13�3'� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ET -Type/Mfg; CASTapacity 2-y� No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r. <br /> Distance to nearest: Well }�O Foundation 1 n Property Line a <br /> LEACHING LINE No. & Length of lines 'fit _ Total length/size <br /> II FILTER BED ❑ Distance to nearest: We4--WW,Ot Foundation Property Line <br /> I� <br /> SEEPAGE PITS t I Depth Size "� Number <br /> f -SUMPS� Ll Distance to-nearest: WellFounation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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, and <br /> rules and regulations,of the San Joaquin Local-Hea4th-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-'-Crontractor's hiring or sub-contracting signature <br /> certifies the following:"i certify that infipections. <br /> rformance of the work for which this permit is issued, I shall employ persons subject to woikman's compensa- <br /> tion laws of Caljforri6." <br /> The applicant must call for all required Complete drawing on reverse side. <br /> Signed X Title: 0"kkw_&� Date: <br /> t <br /> USE ONLY <br /> Application Accepted by y--Date—k =�­ Area, <br /> Pit or Grout Inspection by Date Final Inspection by Dates;%y� <br /> Additional Comments: <br /> ❑ Stk 466.67810' ❑ Lodi 369-3621 ❑ Manteca- 823-7104 ❑ Tracy 835-5385 ^+ <br /> Applicant Return all copies to: Environmental Health Permit/$ervices,1601 E%Hazelton Ave. `.P:O.-Boxr2009,!S1k., CA-95201],, i <br /> IEEE AMOUNT DUE AMOUNT REMITTED K—CASH RECEIVEp BY DATE PERMIT NO. <br /> i <br /> a.EH 13-24(REV.I/k 5) <br /> �j c.Q� <br /> EH 14-2e /v <br />