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-11;00 - <br />APPLICATION, FOR- PERMIT <br />SAN JOAQUIN;LOCAL: HEALTH DISTRICT• <br />1601 E..HAZELTOWAVE.; STOCKTON, CA <br />Telephone {2091 466-6781 <br />��t!1,1-fS'�;•< ;a r j .� ,.:,� 1r• 'f • +( '4- etn, ? i <br />PERMIT EXPIRES .'I,YEAR FROM DATE ISSUED Int tir. <br />.F. 1,(C4mP1ete,in.Tri'p11CatE1.:;'.iii:1v <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:;548:for;sewage orMo, I862•for,well/ purnpsand the.Rules•and=Regulations of the San Joaquin <br />Local Health Distract ca <br />t, �p.s1nlohr W..; 1,11 to <br />Job Address + u. _ ,�, .,... Lot2Size,; PM <br />Owner's Name- <br />icense'No. a3 1A �' Y Phone ✓ D 7" <br />- ... <br />Contractor's Name <br />TYPE OF: WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ +`�- 1, �s•` <br />MP Wc-rm-iATION❑ SYSTEM'REPAIR'❑ i OTHER ❑ <br />PU• <br />DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES DISPOSAL FLD.'" PROP.`LINE <br />M <br />FOUNDATION AGRICULTURE WELL OTHER -WELL PITS/SUMPS <br />INTENDED: USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ IridustHair . - G7 Open Bottom r ❑ Manteca -Dia. ;of Well Excavation 'Dia. of Well Casing. <br />❑ Domestic/ Private ❑ .Gravel Pack ❑ Tracy Type of Casin ' ° Specifications <br />.. ©P Grout <br />ublic ' ❑ 10ther � ❑ Delta Depth of Grout Seal Type of <br />❑-Irrigation - - --Approx. Depth ;❑ Eastern Surface Seal Installed by <br />Repair Work Done ; ❑ Type of Pump H. P. State Work Done <br />(J`� <br />Well Destruction ❑ Well Diameter Sealing Material (top 50) f <br />s„. Depth .,: Filler, Material (Below 50'} <br />V�} <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ID•REPAIR/ADDITION” ❑ DESTRUCTION ll (No septic 'system permitted if public sewer is <br />' -aavailable.wit <br />-^` - in 2 feet.)- <br />-Installation. will! serve: Residence ►! Commercial kOther <br />bedrooms. ri D <br />Number of living 'units: iNumber of t , <br />Character of soil to a depth of 3 feet: j Water table depth <br />SEPTIC TANK ❑ ;Type/Mfg 1 Capaci-No. Compartments <br />_ <br />Method of Disposal <br />PKG. TREATMENT PLT: ❑ r <br />'�16l&l Property Line _/ <br />V <br />Distance to nearest- Well Foundations-.- <br />LEACHING LINE d No. & Length of lines r— Total length/ size 6111P <br />FILTER BED r fl 'Distance to nearest: Well 50 Foundation 9# Property Line ._ <br />,I '. ! — - ' <br />SEEPAGE PITS E : Depth r b _Size i - I I Number <br />;SUMPS ❑ Distance to nearest. Well i A I) Foundations Property Line <br />DISPOSAL PONDS ❑ <br />1 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 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 />o workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />employ any person in•such-manner,as to become subject t <br />certifies the following: 'TGertify that in the performance of the +riwrk for which this permit is issued, I shall employyYpersons subject to workman's compensa <br />tion laws of California." The applicant must call for all r ire inspections. Comloerte drawing on reverse side. <br />Date: <br />Signed X Title: 1 <br />1 FOR DEPARTMENT USE ONLY <br />Area <br />Application Accepted by Date <br />-- <br />_Pit or Grout Inspection by Date Iu i L �' Final Inspection by `• r,� Date <br />0,- <br />7 - <br />Additional Corrlmen'ts: , <br />❑ Stk - 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 - El Tracy <br />Applicant - Return all copies 10 Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 <br />.ural.kM DCkA1TTcn CK .. RECEIVED BY I DATE PERMIT"NO. <br />t i INF <br />+ EN 1324 (REV. 10!63} <br />-- <br />