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APPLICATION FOR PERMIT <br />SAN �OAQUiN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />PERMIT NO. <br />DATE ISSUED42L-1.( <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br />described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br />and the Rules and Regulations of t San Joaqui Loca al District. <br />Jab Address , P N&L&Vr1#A&ision Name <br />i Owner's NameAddress 4j4Wg Phone <br />Contractor's Name License No. Phone <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br />PUMP INSTALLATION SYSTEM REPAIR OTHER U <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA <br />1-1 Industrial <br />U Open Bottom <br />E] Manteca <br />F-1 Domestic/Private <br />❑ Gravel Pack <br />Tracy <br />1-7 Publ is <br />CONSTRUCTION SPECIFICATIONS <br />Dia, of Well Excavation _ <br />Dia, of Well Casing <br />Other ❑ Delta <br />Irrigation Type of Casing. <br />Li 9 Approx, L] Eastern <br />Depth <br />Specifications <br />rl Cathodic Protection p <br />Geophysical <br />Depth of Grout Seal <br />U Other Type of Grout <br />Surface Seal Installed by <br />Repair Work Done E] Type of Pump H.P. State Work Done <br />Well Destruction ❑ Well Diameter Sealing Material (top 501) <br />Depth Filler Material (Below 50') <br />j� TYPE OF SEPTIC WORK: NEW INSTALLATION E-) REPAIR/ADDITION X(,No septic tank or seepage pit permitted if public sewer is <br />�� <br />Installation will serve: Residence' Commercial _ Other j� /�1Q/1P a available within 200 feet.) <br />Number of living units: Number of bedrooms e— Lot size <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK El Type/Mfg �1'� Aeeec Tia Capacity � ,E� No. Compartments <br />PKC. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br />SEWAGESSYSTE ON o Distance to nearest: Well /4_d /Foundation �� Property Line ( <br />LEACHING LINE U No. & Length of lines ,� Total length/size <br />i <br />FILTER BED ❑ Distance to nearest: Well 0Q Foundation 'VIO Property Line J.46 e <br />SEEPAGE PITS Cj Depth Size, Number <br />SUMPS Distance to nearest: Well FoundationProperty Line <br />DISPOSAL PONDS 0 <br />�/` r'-� t A`I r� <br />, ,5 /Jfp isC/�S7`/.(,/z &n4cm 4.�oto —14oiT Lae ilacFlG'e? Ar.., <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county "NZ;TJ4 <br />ordinances, state laws, and 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 <br />permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California.' <br />Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which <br />y' <br />this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />The applicant t call for 1 r ed inspections. Complete drawing on reverse side. <br />Signed X ITitle: Date: <br />��� R DEPARTMENT USE ONLY <br />Application Accepted byy _ _ Area g-- Stk 466-6781 <br />Additional Comments: ❑ Lodi 369-3621 <br />Pit or Grout Inspectio Date D Manteca 823-7104 <br />Final Inspection by Date L7 ❑ Tracy B35-6385 <br />Applicant - Return all capi s o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE, <br />BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />INF <br />�jai <br />EH 13-24 REV. 10/8214(0(� ^ 10182 500 <br />14-26 ��i�'Z! � r� <br />