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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAAL—i ON AVE., STOCKTON'$ CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I.YEAR FROM DATE ISSUED <br /> - {Complete in Triplicate) ((CPO <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 N .549 for age or No. 1862 for well/pump and the Rules and Regulations of the San Joaq yin. <br /> Local Health District. . :.i� ., v f <br /> Job Address �b� "" ® �`r �� City ZIAld10- U Lot Size / S � `�_ PM <br /> = Owner's Name f'eO44A! Address��Js 3 ��iS�XE Dw /�i�/I�� G�'"Phone Z -L <br /> Contractor's Name 'fix cense No. _._ Phone <br /> TYPE OF WELL/PUMP:. NFWWELL - WELL REPLACEMENT ❑ # DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ER <br /> ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK,11:)(5' " _ SEWER LINES .DISPOSAL FLD. PROP. LINE <br /> FOUNDATION %tC AGRICULTURE WELL OTHER WELL., PITS/SUMPS <br /> INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICA�TIIW _. /f <br /> ;❑ I ustrial "Open Bottom 17 Manteca Dia. of Well Excavation ` Dia. of Well Casing <br /> DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing S €'fit Specifications <br /> t❑ Public ❑ Other ❑ Delta Depthof Grout Sea] Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern . Surfaoe Seal Installed by t lFUE Z74 ~' <br /> Repair Work Done ❑ Type of.Pump .P. ! State Work Done <br /> Well Destruction ❑ Well Diameter Sealin Material Ito 50'1 <br /> Depth'"~ - � Filler.Material 16elow 501 ry',v <br /> \ <br /> �� _ , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 71REPAER/ADDITION 13 DESTRUCTION C1 (No septic system permitted if public sewer s:;-�-; <br /> available within 200 feet.l C <br /> Installation will serve: Residence_ Commercial Other- ' <br /> Number of living units: Number of bedrooms'`� Y <br /> Character of soil to a-depth of 3 feet:4_rr"" � �� . - _— V 1Nater 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 /> LEACHING LINE ❑ -No. & Lendth of lines F -_ Total length/size <br /> ,FI1:TER'BED---­10—Di6fance t nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth '° Size Number 'SUMPS 13❑ 'Distance to nearest: Well^ Foundation" Property Line <br />{ DISPOSAL PONDS ❑ <br /> I jhereby 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 /> CHome owner or licena <br /> sed gent'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 /> I 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." C <br /> The -applicant m II for all ri red inspections. Complete drawing on reverse side. <br /> ��s-�5 OU <br /> Signed l Title: Date:T . <br /> FOR DEPARTMENT USE ONLY <br /> Application.Accepted.by — - — Date `� Area <br /> Pit or Grout Inspection by ! �te Final Inspection by - Datef�! <br /> Additional Comments: <br /> ❑ Stk 466-6* ❑ Lodi 369-3621 ❑ Manteca 823-7104 b Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20.09, Stk., CA 95201 <br /> FEE <br /> µ <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"NO. �_ <br /> r f <br /> +EH 1324 IRE'.101831 V �. „7[JIP•' 1 �— Ql <br /> �p` ��i— Of�� r <br /> N EH'14-28 a. <br />