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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> F I <br /> Joh Address 12731 lJ@EAJ GU'iT_UPjY —jj- <br /> City1JL1 Lot Size � ac PM <br /> �7 r <br /> Owner's Name iiu LTg .T!_'h_1611 LFi� Address '��1'�' Phone 4-62"2y5 1 <br /> Contractor Kul Z�& G.1L + Address r Bud 76 License N077585 Phone_554-4725 I` <br /> TYPE OF WELL/PUMP: NEW WELL -n WELL REPLACEMENT ❑ "' DESTRUCTION 0 �•�+, <br /> PUMP INSTAL <br /> _L_A__TION,ER__ _ _ —SYSTEM REPAIR,El- _� " - _ OTHER._❑r._ <br /> DISTANCE EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ° FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J <br /> 0 Industrial j l❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 112 <br /> Domestic/Private i '-&Gravel Pack ❑ Tracy Type of Casing >' 'i Specifications <br /> ❑ Public F] Other FI Delta Depth of Grout Seal 5�' `feet Type of Grout Cemetlt <br /> t <br /> 11Irrigation !h� s 2L_.Approx, Depth 17 Eastern Surface Seal Installed by "'COQ. 1"aG"'i.QY' <br /> �RepaiilWorrk Done; Type of Pump sub H.P. 7 State Work Done _Cf111��c'zC LOQ' <br /> C <br /> Well Destruction ElWell Diameter Sealing Material (top 50'1 1 <br /> ` 14' Depth Filler Material (Below 50') <br /> F <br /> TYPE OF SEPTIC WORK: ;NEW INSTALLATION 1] REPAIRIADDITION 1 1. DESTRUCTION l I (No septic stem permitted if <br /> V P Y p public sewer is <br /> I <br /> available within 200 feet.) <br /> Installation willst rvei Residence— Commercial_ Other <br /> Number jof living-units: 1 Number of bedrooms O <br /> Character of soil to a-depth of 3 feet:— —----- ------Water-tableldepih <br />,.;;. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br />,y ( PKG. TRfATMENTiPLT. ❑ `.' Method of Disposal "" <br /> 'I 'D st nce•to nearest: "Well Foundation Property Line ' <br /> r <br /> LEACHING LINE ❑ No. & Length of_lines. Total length/size ^ <br /> FILTER BED ❑ Distance to nearest: !Well Foundation Property Line <br /> SEEPAGE PITS : I I Depth f ' ) Size Number <br /> {\� SUMPS LI Distance to nearest: ' Well Foundation Property Line o! <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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.Diktrict- <br /> Home owner or licensed agent's signature certifies the,fgllowing:-'l�cert_imthat-in the performance of the work for which this permit is issued, I shall not r <br /> employ any person in such manner as to become subject'to Wofkman's copensation laws of California." Contractor's hiring or sub-contracting sigrfatu <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 <br /> The applicant mus atl fo~all equired inspections. Complete drawing on reverse side. \C\]Y <br /> F <br /> Signed X Title: IJ 1TP­tL Date- 6-15_'8 ? <br /> i FOR DEPARTMENT USE ONLY (� C� <br /> Application Accepted by Date �+' �� 1 Area <br /> t <br /> Pit o Gr ut Inspection by ate ' Final Inspection Date <br /> Additional Comments: <br /> O Stk"%6-6781 ! ❑ 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 95201FEE ` <br /> ~ INFO ="AMOUNT_DU E - .�--AMOUNT REMITTED' -CASH "" =RECEIVED-BY, DATE Y 'PRMiT tJO. <br /> y <br /> �l f <br /> +.EH 13-14/REV. r K sl <br /> £H t4-2(S / �./ (r ✓ y~� e S /^ ��J V / _�JZI E <br />