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APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> a, Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 0�� <br /> {Complete in Triplicate} �=.J >U <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 /> Job Address L OL wl A. City�JV Lot Size PM <br /> Owner's Name �i} Address Phone 4 � <br /> ContractormDyri5s1aC Address 1. <br /> License No-Ow L--Tq—Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> "OTHER ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK S ER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AG CULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Mantes Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack-- ❑ Tracy Type of Casing Specifications <br /> M Public CI Other n Delta Depth of Grout Seal l <br /> Type of Grout <br /> I 1 Irrigation —.-Approx. Depth I I Eastern race Seal Installed by <br /> Repair Work Done ❑ Type of Pump- H.P. State Work Done_ <br /> Well Destruction Cl Well Diameter Sealing Mate al {top 50'1 1 <br /> Depth Filler Material eiow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I D013 <br /> ESTRUCTION t l {No septic system permitted if public sewer is <br /> available within 200.feet_) <br /> Installation will serve: Residence Commercial V Other <br /> .Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SE C TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. T ATMENT PLT. ❑ Method of Disposal <br /> f�1L S Distance to nearest: Well Foundation Property.Line <br /> 3 LEACHING LINE [1 No. & Length of lines <br /> Total length/se <br /> FfLTER BEDca, ❑ ..Distance tQ nearest wen r S i- i Foundation _ -Property Line _ ""•'=y '� ,s - . <br /> .. <br /> � Y�SEEPAGE PITS ti � .• �� :Oepth� ,-e"� ,� Sim ".�� >l ` :.Ntimbet-'� `"` :'%k'- 1f►i;.'��, "-- <br /> �"�3:?sw��"r? s� ���tane�'`�e"�neare3t �1�Ve�� .� •'° Foundation x -�4 �'r� .s"-��� -'rte <._. � " '��$ <br /> :D ISPOSALPONDS <br /> a� �, fy,�,�„e,� P,�pa�ed fFiis app 1�eabon'and�t'the`work'�i be d'-one irs�eccazrdanc``with�$an.Joagwn-county ardir�attaes�te°'fa`` hand -- <br /> ales andregellaaonsSe urn L - ealth�Dtstnct �, <br /> o`orne o°tn+otivor ice F'aa ei�t'�` m'` *� � M <br /> �. Ma ,. 9 si9nature.ce tfte fa'�oMnrtg itj ga"t 4 �tsl1�" orntanoe 61.8 <br /> 8mploy any.person�lr,such niter as.to become sub a " - ;. 011k � �h,- . C note <br /> ' ""• '• ° -� rrr. - «a. ' rrsan scompenat�rorfawsiofCaldomtaCon urng' 5ttrae si nature s, <br /> certifies the folfowin F.cerac s h <br /> r g.' rttfy that rndheperformance of the tiirork for whicFi this permit rs'issued,1 sha I em sol s <br /> tion laws of Califorriis ' "r x f PI°y _ s campensa <br /> stn •�� ��°k.a Jp��'��k^��n���'`i•^7`b'a�.`�`� �� �... <br /> 9. - r,a. .ice :.�rt ' <br /> ti <br /> The applic ust cal!for"all required inspections'Compfate thawing ori reverse" <br /> side <br /> Signed <br /> Title: <br /> so�.�l�U <br /> . . ate. <br /> { FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3-ag_ 'qm <br /> -'Pit or Grout Inspection Datepection by Date 10- <br /> Final Inspection , <br /> w Additional Comments: iv <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8Z3-7104 ❑ Tracy 835-p85 <br /> Applicant- Return all copies to: Environmental Health Permit/Sarvices 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA"95201 <br /> " 1 <br /> FEE AMOUNT DUE: AMOUNT REMITTED <br /> INFO �t RECEIVED 8Y DATE PERMIT-NO. <br /> �.EH 13.21(REV. i w sY +' O /��� 11{ <br /> EH 13-28 { ` l 1S 7 1 <br />