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ct <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON, AVE., STOCKTON, CA Q�SN <br /> Telephone (209) 466-6781 VI\A 15 0 <br /> PERMIT EXPIRES 4'YEAR FROM DATE ISSUED 1�G�� ��� ,.� <br /> (Complete in Triplicate) Q�c�'�5�� <br /> t T 4�� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andfAi s€a or'�r described- This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/purr and the e and Regulations of the San Joaquin <br /> Local Health District. r <br /> Job Address 3 f 3 -rr City A,1f Lot Size PM <br /> Owner's Name 11119W-640Y ZA4" ' ;O�Address /T G� �- Phone <br /> ContractorL / License NoD � Phone ? S— <br /> TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIOI1� 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 SPECIFICATIO S <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing g <br /> i <br /> E Domestic/Private 2-Gravel Pack ❑ Tracy Type of Casing __ Specifications lVG-2-y7" <br /> 1-1 Public Other ryl6/rlTj'✓ {_l Delta Depth of Grout Seal l.J­6 Type of Grout <br /> t <br /> I I Irrigation _.Approx: Depth I I Eastern Surface Seal Installed by, <br /> Repair Work Done ❑ Type of Pump h H.P, _ ���_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth { Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms /I <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 /> j <br /> } <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> t <br /> FILTER BED ❑ Distance`to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth __ _______ Size Number <br /> SUMPS Li Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ortate laws, and <br /> rules and regulations of the San Joaquin Local Health District. ``�SNA <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for w iS 111 t r It is issoedf J shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Co r,'s hhilh -contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall � rr`t`b�s l o workman's compensa- <br /> tion laws of California." <br /> The applicantmu call for It ed inspections. Complete drawing on reverse side. SPNN�`;�• �c,�i' <br /> Signed X Title: A�i13�1J Date: 2 <br /> F R DEPARTMENT USE ONLY <br /> Applic/,ncepted by +"'�G"� Dare u Area <br /> Pit or Grout Inspection by �/J�T—� �D�atee ` Final Inspection by �r Date <br /> Additional Comments: �+° !`��1 C� 4"V w1�79 ��7,� -T Fy Z _� Z/�� f <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 1335-6385 <br /> Appticant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> sae <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CA([S�(H <br /> ♦.EH13-24MEV.tinsi S`t�v ]35 <br /> EH 14-26 t <br />