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7 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRIM r� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS <br /> (Complete in Tripl e <br /> IM�I3y;�y, <br /> Application is hereby made n the San Joaquin Local Health 549for fora permit to con � T he S ion is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or Nom: wmen t an Joaquin <br /> Local Health District. ao✓+s. <br /> 1 1Adrf / <br /> Job Address k.x,i kc kjL V141 L, IA-�1� City ` �'' '`� Lot S ze /00 X I adp/ PM <br /> �: 1' l� � dY•� f11 w.2Kb-T 1��4�i..a,- $r.><,t.,).,,-rc.T Sr , rot,✓rv1.. <br /> Owner's Name �o0 .rti11�c. I rr^'r5 A dressn Fi^a HGtsW er(r QUIDS' Phonal` --5-441 <br /> 11`f `ZfMcrtU Cv✓GbC�v1- <br /> Contractor 'AIgz� i•1AZMW-T Address_26;1­431512_rQ_120H-O ST License No,�5J�� hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ t%r WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION v SYSTEM REPAIR El OTHER ❑ <br /> ,n. <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES �> 1 Q O DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Tr L Specifications Cp-,v„ati>T <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ . <br /> I I Irrigation _Approx. Depth I astern Surfac Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 501 <br /> Depth 2� Filler Material (Below 501 v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is (V <br /> available within 200 feet.) R <br /> Installation will serve: Residence_ Commercial_ Other V <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: 'st\-T 2 C-LA-1 S t <br /> SEPTIC TANK ❑ Type/Mfg Capacity01 <br /> part <br /> PKG. TREATMENT PLT. ❑ th \ o I <br /> Distance to nearest: Well Foundation Property a �— <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <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 certifies the following: "t 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." <br /> The applic t mus call o a ired inspections..Com lete drawing or ee�vrse side. <br /> Signed p Title9�—>C/'//O (,<Y6_ez v4-/ST Date: 'D <br /> OR E TMENT USE ONLY <br /> Application Accepted by Date/v /� At" <br /> / C <br /> Pit or Grout Inspection by Date ,ILf,- v Final Inspection byDate <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE'RM17 NO, <br /> ♦.EH 113/IREV.t/x51 / / 1117 <br /> 10 <br /> EH U-28 <br />