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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 14 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED d <br /> {Complete in Triplica# <br /> Application is hereby made to the an 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address /_ 045 �.f�r " �t City" Lot Size ` e_e_ PM. <br /> 'r Owner's Name Address _ ?�. Y, = Phonecyg/_233qUJ <br /> - <br /> i <br /> hi r. I `� <br /> Contractor . Address rV License No� Phon " 7 d <br /> TYPE OF WELL/PUMP.- �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP,iINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> -- o- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v <br /> INTENDED USE TYPEf OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS n <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 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i <br /> ❑ Irrigation r1 ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> .,F <br /> Repair Work'Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction C1 Well Diameter Sealing Material{top 501 <br /> Depth �M Filler Material (B61bw 50') <br /> STYPE OFiSEPTIC WORK: NEW1K9TA6TION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> l i II`` ' available within 200 feet.) <br /> Installation will serve: Residencle— Commercial— Other— _ <br /> Number of living units:_ �Number-of a ooms �,.-�---�-- "` ! <br /> 'iCJLEharacter of soil to a depth of 3l feet: Water fable depth <br /> STANK ❑ T eM/Mf y" ,v.. �. vo. <br /> .,�t4EPTIC, ..r-» � YP 9 _ � Capacity .p Compartments � � • <br /> G. TREATMENT PLT. ❑ t <br /> jMethod of Disgosal <br /> r j <br /> Distance to nearest:. WeII Foundation ,� y <br /> Property Line _ <br /> s9J.�NG. INE No. & Length of lines Total length/size 1� } <br /> �O�;� FI LTEfi BED. ❑ Distance to nearest: Well Foundation Pro <br /> � perty Line <br /> SEEPAGE IPITSI Depth ' Size Number <br /> SUMPS I ❑ Distance to nearest: Well� Foundation 1 /� Property Line <br /> DISPOSAL PONDS . ❑ �� <br /> I hereby,certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and <br /> rules and regulations of the San Joaquin Local Health District. t 1 <br /> —"Homeowner or agent's ` 'tfie_followin <br /> �.licensed 9ents si 9nature certifiesx gi "I certify that in the performance of the work for which this permit is issued, I shall not <br /> as <br /> employ any parson in such'manner. to become subject'to workman's compensation laws of California."Contractoes hiring or sub-contracting signature <br /> certifies the follgwing:� 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." 4 !la <br /> f ..�. w <br /> The applicant t call fon all requi nspections. Complete drawing on reverse side. _ <br /> r <br /> Signed i Title: Date: Cd S E; <br /> FOR DEPi4RTMaEN7 USE ONLY 0i <br /> Application Accepted by Date Area 6 <br /> - rt r Grout IrisPWtio`ii 'bv. Date din Inspection by at�'- <br /> Additional Comments: <br /> ❑ Stk 466-6781 ID Lodi 369-3621 ❑ Manteca 623-7104 11 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 /> INFO AMOUNT DUE . AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> Jy <br /> + EH 13-24(REV.iia 51P-..a <br /> , _ T - iEH 14-26 <br /> 1 <br />