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15 <br /> ., <br /> APPLICATION FOR PERMIT - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - i 9- _:AA3 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA n� <br /> Telephone 12091 466=6* <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '. <br /> {Complete n �v cIn.Triplicate} "' Q <br /> (rl -7 <br /> am/ —O-I <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 Ryles and Regulations of.the San Joaquin�'t <br /> Local Health-District. � r �• ���d �?_,t,�� <br /> Job Address F '- E- o 3 City y Lot Size PM <br /> ttl9t <br /> r ry <br /> Owner's Name, Address ='='= "' --n Phone <br /> Contractor KVIFAW&R ±Ubc_ Address License.No. i Phone –13 4-S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,.. DESTRUCTION ❑ � . <br /> PUMP INSTALLATION Ll SYSTEM REPAIR ED �' OTHER,'&[[ ~:�L�11}�(A)(r {5 <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 ir <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation au Dia. of Well Casing <br /> ❑ Domestic/Private l Gravel Pack ❑ Tracy Type of Casing fe Specifications <br /> I <br /> Public- ElOther ❑ Delta Depth of Grout Seal I MW P� I ,) Type of Grout�ti +k <br /> irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> r Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ :REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ` available within 200 feet.) <br /> ' Installation will serve: Residence_ Commercial— Other <br /> I Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t LEACHING LINE ❑- No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t . <br /> h <br /> ( SEEPAGE PITS ❑ Depth ):SizeNumber <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> r DISPOSAL PONDS ❑ <br /> i 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 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 /> employ any person in such manner as to become subject to workman'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." <br /> The applicaI== inspections. Complete drawing n reverse side. <br /> Signed X �' Date: <br /> // FOR DEPARTMENT USE ONLY p <br /> 17 <br /> Application Accepted by —� Lam% �'� Date r � Area r <br /> Pit or Grout inspection by Da Fina Ihspecti n b �� ate/x~���� <br /> Ste-, <br /> Additional Comment <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83556385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH .RECEIVED BY DATE' PERMIT•'NO. <br /> t <br /> `+ EH 13-241REV.t/a5) Ae _..g -.b. - «. J•,� ^fC�c - , <br /> - - — - - <br />