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}9rr, rt APPLICATION FOR PERMIT - fkl'1 cc_uo� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA R AYMzhr <br /> Telephone (209) 466-6781 EGel VIED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 2 r <br /> (Complete in Triplicate) AA''yy,, `� ��88 <br /> 5� ��i made to the San Joaquin Local Health District for a permit to construct and/or inst�NVJRQV scribed. This application is <br /> co r� nce with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th4"M' tf ?San Joaquin <br /> L al Health District. 'yl!! S r rT <br /> Job Address 02— �y �� ��d�L/d City of Size PM <br /> Owner's Name -t~ Cf --Address �" /1[r �}l �C /- / `� Phone l�gr—,7 <br /> Contractor��L � L��2N6��% Address License No. S� .7Phone �11JI_JDZ <br /> TYPE OF WELL/PUMP: NEW WELD" WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 474 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION .i <br /> Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EJ Domestic/Private GravelrPPack ❑ Tracy Type of Casing �/ �� Specifications <br /> 1-i Public l�Othetr�n '.t,°f�?Y ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I irrigation �,-Approx. Depth I 1 Eastern Surface Seal Installed by /7-1/1/ ,_1 f 9-C-el <br /> Repair Work Done ❑ Type of Pump yflfh H,P. State Work Done _ <br /> e <br /> Weil Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 501 Q <br /> TYPE OF SFPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I 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 kA <br /> Character of soil to a depth of 3 feet: Water table depth r 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of,Disposal <br /> Distance to nearest: Well Foundation Property line i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size— <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line l� <br /> SEEPAGE PITS - FI Depth Size Number <br /> SUMPS L7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Californi <br /> The applicant mus all f all re Pre in pections. Complete drawing on raves side. ,/ j01 <br /> Signed X Title: 1 _d Jf/ �� Date: r® Q <br /> 7 �T <br /> FOR DEPARTMENT USE ONLY Q� <br /> Application Accepted by Date tee! Area <br /> Pit or Grout Inspection by Date +y� Final Inspection byXDate 3 p <br /> Additional Comments: I�z <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AM <br /> ,O <br /> +UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> +.EH 1 -24IREV <br /> EH 144-26 V" 0 O� 1 1l3��S a14 C <br /> 1 [[ l <br />