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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate). <br /> • i <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.No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ' <br /> G02 <br /> Job Address G02 !(e 7 A.1NZ t2 7 City eV 7_42 � Lot Size / PM f <br /> Owner's Name _ - �lc'l�.>veGG Address �ySPhone I`l <br /> Contractor i�i /`"CJL[-C~ _Address 6 2 /1 License No-6Z09 hr Phone $ 11 �' <br /> TYPE OF WELL/PUMP!, ` NEW WELL WELL REPLACEMENT- "� _ -DESTRUCTION ❑ O <br /> PUMW-INSTALLATION ❑ 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 SPECIFICATIONS j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ,-j``-- ❑'Other " _, "" ❑ Delta--- "D`epth­_af GFoui Seal`{" __ Type of Grout j <br /> ❑ Irrigation, '� ; ---Approx. Depth ❑ Eastern Surface Seal.Installed by <br /> I <br /> Repair Work Donee ❑ Type of Pump H.P. State Work Done_ <br /> 1 <br /> Well Destruction ❑ Well Diameter- Sealing Material (top 50') <br /> Depth i Filler Material (Below.501 , <br /> TYPE OF SEPTIC WORK: NEW INSTALGiNTION_ REPAIR YADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) i <br /> ( Installation will serve: Residence commercial, • Other' <br /> .r <br /> Number!of living units: T 1 Number of bedrooms <br /> Character of soil to a depth of 3 feet: S�!!�/]E/ � (t Ni. Water table depth I <br /> a SEPTIC TANK Type/Mfg Capacity ' t No Compartments <br /> PKG. TREATMENT PLT. ❑ ";_,.__,_ rte F7— Method pf Disposal t <br /> Distance to nearest: Well Foundation �76 Property..LinerLArZ ,�7 <br /> F <br /> LEACHING LINE X--N.. & Length of lines �d f''^T Total length/size <br /> FILTER BLD ❑ Distance to nearest: Well/t5i�Foundation 3D Property Line <br /> SEEPAGES PITS ❑ Depth Size Number ;� 4✓ F„�p I it <br /> SUMPS ❑ Distance to nearest: Well Foundation Peop rty Line f <br /> DISPOSAL PONDS (A <br /> 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. Fx # <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the:7erformance of the work for which this permit is issued, I shall not }ft <br /> i employ arty person in such manner as to become subject to workman's compensation laws-of California., Contractor's hiring ot;sub-contracting signature <br /> certifies tie followirigc”("certify that in the performance of the work for which this permit is issued, I shall employ persons stibjbc't to workman's compensa- <br /> tion laws of California:" ` <br /> The applicant must call for all quir� spections."Complete drawing on reverse side. <br /> Signed X x r � ..moi -� .Title " Date: <br /> 'FOR DEPARTMENT USE ONLY i <br /> fj <br /> Application Accepted by �/�'"'� Date Area <br /> Pit or Grout Inspection by Date Final Inspection by j Data fO <br /> Additional Comments: Y ! <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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT-DUE- �AMOUNT REMITTED' CK. '_ 'a- RECEIVED BY' - uDATt PERMIT'NO. N <br />�.� INFO CASH <br /> _ r <br /> + EH 13-24{REV. /R 5) <br /> EH 14-28 O Hca O <br />