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I APPLICATION FOR PERMIT <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> q�(0 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 <br /> made in compliance with Sart Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address <br /> City .J Lot Size PM <br /> Owner's Name y CddlZI fly �!�•Address N. •✓CG�}[ j 319D-3 <br /> PhoneContractor AddressLicense No. $3/O PhoneZ-TYPE OF WELL/PUMP':t � W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑UMP ALLATION,X SYSTEM REPAIR ❑ OTHER � �&1J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D1SP05AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL• OTHER WELL PITS/SUMPS <br /> INDEX USE r TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> NIT�IZ ❑ Open Bottom ❑ Manteca .i.3 Dia. of Well Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private Gravel Pack ❑ Trac , <br /> Y Type of Casing x Specifications <br /> Public ❑ Other ❑ Delta Depth of Grout Seal TypeofGrout lB )PAWI r <br /> ❑ Irrigation geApprox. Depth F-1EasternSurface Seal Installed by <br /> Work Done ❑ <br /> Repair WorType of Pump Su�M• H p State Work Done <br /> i„ f .. <br /> Well Destruction El %W11 Diameter 9��15 7 Sealingl Material (top 50') ­ &241 7<T <br /> Depth ► Filler Material (Below 50') 414,'743 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AD1DITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ <br /> Installation will serve:� Residence— Commercial— Other <br /> available within 200 feet.) <br /> Number of living units.: Number of bedrooms <br /> Character of soil to a depth-of 3 feet: Water table depth <br /> SEPTIC TANK '' <br /> ❑ Type/Mfg I Capacity INo. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> t - - Method-of-Disposal <br /> ' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' — ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ------------------------------------------ <br /> SEEPAGE;PITS L�❑ Depth Size Number- <br /> SUMPS. ..{-• - -- -�^O Distance to nearest: .WeII .Foundation -- ----Property Line <br /> DISPOSAL PONDS Elf ­T g <br /> x I -- ----�- "s !' <br /> I hereby certify that I have prepared this application and that the work will'be ddne,io-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."Contractors hiring or sub contracting signature <br /> certifies the following:"I certify t 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 Californ- .' TT f E fi <br /> The applica t s or II a uired'ins ctions. Complete drawing on reverse side. LL _ :�A <br /> Signed��f� <br /> Title: ' Date- f �+�y <br /> y FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> y� Dates 2A <br /> Pit or Grout Inspection by Date `� ina( Inspection by Date <br /> Additional Comments: 1aF!` �^r� � �' <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 <br /> Applicant n Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CKR RECEIVED BY DATE' PERMIT'NO. <br /> + EH 13-24IREV.t/B5] - ? n� ��� w _•��� s� x r <br /> EH T426 v a <br />