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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> 1601 E. HAZEtTQN AVE., STOCKTON, CA r <br /> Tel $Ohe (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described This application is 1 <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 31;z z/ 1 ' City PM `"[ <br /> '�-�$- <br /> Job Address l <br /> dd Phone <br /> Owner's Name _ _ 7ALfess ___,_.�� _,_.__� __ <br /> S 6`' -L-icense No. Phone,_ <br /> Address <br /> s <br /> TYPE OF WELL-!POMP: -\;NEW WELL ❑' j WELL REPLACEMENT ❑ \JJ DESTRUCTION E3171l ` <br /> PUMP INSTALLATION F1 SYSTEM REPAIR OTHER ❑ <br /> DISTANCL TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> \ FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> ON <br /> INTENDED USE TYPE OFIWELL PfrOBL'EM AREA CONSTRUCTION SPECIFIC.ATIONS <br /> 63 iS <br /> ❑ Indu_strial ❑ pen Bottom If.Manteca ;Dia�,,�',�ell Excavatiab-:f".` �J� Dia. of Well.-..Casing <br /> "D Domestic/PrivateO L3'+Gravel Pack ❑ Tracy y. Type of Casing Specifications i <br /> 'Il 1 Public I ," the/ e + n Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation �_Approx. Depth ;,].Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of_Pump ! {{ H.P. � £State Work Done t <br /> Well Qest�uction ❑ We11 Diameter \3 Sealing Material [top 50'1 <br /> pepthr Filler Material4,11ow 501 <br /> TYPE OF[SEPTIC WORK: iNEWiINSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I i. 1No septic system permitted if public sewer is <br /> tt11 � available within 200 feet.) <br /> Installation will serve: R estde)ce Commercial Other <br /> Number of living units: Number of bed ms, 3 <br /> Character of soil to a depth f_3 feet: �" ' -- -- ':'ater-table-depth- <br /> SEPTIC ANK —❑ Typeymfg �- Capacity k No. Compartments <br /> PKG. TREATMENT Pb . �Dist 4 / f 1_ Method of Disposal <br /> st: Well J , 'Foundation A Property Line <br /> LEACHING LINE � 4 No. & Length of lines � dotal length/size �, <br /> FILTER BED Z ❑/P/ <br /> ist rice to'�nearest: Well &22 Foundation Property Line, I <br /> r <br /> SEEPAGE!PITS I Ij/Depth \, Sire Number \�,k. , ' `; 4 <br /> SUMPS ❑i DtVabb�`tnearest: Well Foundation _j Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared-this pa plication and that the work will be' done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of-ti;; San Joaquin Local Healt=,Alstrict. <br /> Home owner or licen'sed agent's signature certifies-the following: "I certify that in the perfor ante of the work for which this permit is issued, I shall not <br /> employ any perdi in such mariner-as-to-bwcome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> slo <br /> certifies the following: "I c�r4ffy that in the performa�.of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br />! tion laws 'of C41ifornia." <br /> r <br /> The applicandnust ca)l or all required inspections.(Coplate drawing on�feverse side. <br /> P ) ATO <br /> Signed X, Title: ' Date: <br /> F R PARTMENT USE ONLY <br /> k U <br /> Applicati n Accepted by r Date Area <br /> ! t <br /> Pit or Grout Inspection by ri Data t Final Inspection by Date r _2 <br /> l �{ �! .1 <br /> Additional Comments: <br /> ❑ Stk 4r6�6781 © Lodi 369-3621 Cf Manteca 823-7104 ❑ Tracy 835-6385 <br /> ApplicantReturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEENFO AMOUNT DUE AMQUNT REMITTED KSy REd VED I3Y r DATE PERMIT NO. j! <br /> t.EH 1344 IAEV.r� <br />