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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 'E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> (Complete in Triplicate) <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and/or install the work herein described.This appli Mian is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage o1r:No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. MW <br /> ]�(j ✓' 1'r+T �`+ <br /> • <br /> Job Address es X11 ' -lL' .fir HrMZ1l�}�A��SLa CitYTi-9k4f r-rl Lot Size PM ' <br /> Owner's Name Gr "iIreT _ Addras25081 _Grakp l N Phone <br /> Contractor's NamarY��t_ I.Zl-D �ltse No. Phone <br /> 727-3119 <br /> TYPE OF WELL/PUMP: NEW WELL LJ WELL REPLACEMENT U DESTRUCTION U <br /> i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 1 <br /> p DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTALI TION SPECIFICATIONS <br /> ❑Industrial ❑Open Bottom 0 Manteca Dia.of Well Excavation Dia.of Well Casing <br /> ❑Oornsaft/Private CJ Gravel Pack ❑Tracy Type of'Casing Specifications , <br /> "u Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout r <br /> ❑ Irrigatiorf_ --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. 1 - Stets Work Done 4 t a em ?U <br /> Well Destruction ❑ Well Diameter Sealing Material(top 50') <br /> Depth . Filer Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION Ei (No septic system permitted if public sewer is fi <br /> available within 200 feet.) <br /> 4 <br /> Installation will serve: Residence— Commercial— Other <br /> t Number of living units: Number of bedrooms <br /> Chw&mer of soil to a depth of 3 feet: Water table depth 1 .. <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT.{3 Method of O*>osel <br /> Distance to nearest: Well foundation Property Line <br /> r <br /> LEACHING LINE ❑ No.&Length of lines Total length/size <br /> I FILTER BED 0 Distance to nearest: Well Foundation. Property Line <br /> n <br /> SEEPAGE PITS ❑ Depth. Size Number <br /> SUMPS ❑ Distance to merest' 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 I,'an Joaquin scanty ordinances.stele/awe.and <br /> 4 rules and regulations of ttte San Joaquin Local Health District. n issued.I anon not <br /> Horne owner or ncensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit <br /> employ any parson in such manner as to become subject to workman's Compensation taws of California."Contractors hiring w strb Cantrectirtg si0netu►e <br /> crtifies the following:"I ray that In the prma <br /> erfonce of the work for w1 t:h this,permh Is issues.1shat/employ persons subject to workman's compensa- <br /> etion taws of Caltfo nis." <br /> The applicant m Can for all required in ctlon drawing on reverse 3 <br /> Signed /^r Title: Date: <br /> - � f FOR DEPARTMENT USE ONLY r � <br /> Data r –� Area <br /> Application Accepted by y f ct Ct.IJ Date <br /> Pit or Grout Inspection by Date Final inspection b1 <br /> Additionsi Comments: <br /> 0 Stk 466-6781 ❑ Codi 389.3ti21 ❑Manteca 823.7104 Q Tracy B3r8365 a <br /> Applicant-Return all coplas to: Environmental Health Pem>iVServiCee 1601 E. Hereto"Ave_ P.O. Box 2009, Stk.,CA 9=1 <br /> FEE AMOUNT DUE AMOUNT AEMITTED CASN RECEivED By DATE PeAmn NO. <br /> INFO <br /> a EN 11-241REV.4e183V �, tap �""� � ss S�1 <br /> FH 1/-26 <br /> ,�'•-r--".�„"-R *"-",�""" ---T _r a'� +.;4 <br /> < <br />