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APPLICATION FOR PERMIT L} 7S"T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 7 _ <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED Ktt t V4­ <br /> b <br /> (Complete in Triplicate) SEP 2 1 19110 L� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule �}arol�lit�la�ip�sfthe fr�n Joaquin <br /> Local Health District. � Cf[E i S 1? N <br /> Job Address 4 City O Lot Size PM <br /> Owner's Name L aia.,�,✓I _ U__ __ Address.?o p 1.� ��e l�_ eC ,,� Phone 34 O <br /> Contractor )!�ZVZ plc Address License NoL 13 Phanq cn 6196 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Z SYSTEM REPAIR El 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 SPECIFICATIONS t <br /> 0 Industrial ❑ Open Bottom fO.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing {Specifications <br /> Fl Public ❑ Other ❑ Delta Depth of Grout Seal !Type of Grout _ <br /> I&,M igati`on- ­.Approx. Dg*h 11 I Eastern Surface Seal Installed by I _ <br /> �. a <br /> Repair Work"Done ❑ Type of Pump '"'`� H.P. _Z0 State Work Done_ �� Al <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 lNo 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 _ <br /> Character of soil to a depth of 3 feet: t .-'—Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity r. No. Compartments ` <br /> 1 � <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <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 /> I <br /> SEEPAGE PITS I I Depth ) Size Number <br /> SUMPS ❑ 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 certifiei ffie 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." 1 <br /> The applican ust call for all re uired inspections.-Complete drawing on reverse side. <br /> Signed X ) it4e: � Date: <br /> r � <br /> 1' <br /> EGOIDEPARTMENT USE ONLY <br /> Application Accepted by Date "zJ 1v Area <br /> Pit or Grout Inspection by Date Final Inspection by � -Date�U–iJ—�c7 <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EE CKO <br /> INFO AMOUNT DUE AMOUNT REMITTED �.CASH RECEIVED BY DATE PERMIT"NO. ' <br /> r.EH13-24(REV.)/x51 <br /> 4 <br /> EH 14.26 IZ��(� <br />