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Zn COP,AA <br /> { APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-8781 <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 /> I made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> -- -_ <br /> Job Address <br /> t3ob <br /> Owner's Name��/T Address / 7� .(�. � 1�,� 6j <br /> Phone qq2°Z 3 S$ <br /> Contractor_ -LnAl} _!f,! AddresN°+�v�LSc�ry I License No �/�� � phoceY ��s 47 <br /> TYPE OF WELL/PUMP: NEW WELL p <br /> PUMP INSTALLATION El WELL REPLACEMENT DESTRUCTION ❑ <br /> ,r <br /> DISTANCE TO NEAREST: SEPTIC T SYSTEM REPAIR I-] OTHER CI <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. <br /> IINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Weil Casing <br /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing--_ Sera <br /> ❑ Public ❑ Other ❑ Delta Depth of"Grout Seal Type of Grout <br /> 1 ❑ lirigation ---Approx. Depth Ely Eastern Surface Seal Installed b <br />` s �Vl <br /> Repair Work Done 11 Type of Pump H,p, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ill <br /> i Depth Filler Material(Below 50'1 !u <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system <br /> I permitted if public sewer is <br /> available within 200 feet.) <br /> > Installation will serve: Residence X Commercial_ Other <br /> Number of living units: Number of bedrooms ff33, <br /> -t _. <br /> I <br /> Character of soil to a depth of 3 feet:_ 1, Water table depth <br /> SEPTIC TANK 'S Type/Mfg +�,t'IS�F Capacity-d No. Compartments Z <br /> PKG. TREATMENT PLT. ❑ O _. Method of Disposal r <br /> Distance to nearest: Well -5 Foundation l� Property Line: S <br />' LEACHING LINE ❑ No. & Length of lines Z Total length/size <br /> 4 FILTI R BED ❑ Distance to nearest: Well­�� Foundation_ lOr Property Line <br /> SEEPAGE PITS ❑ Depth Size Z-31 Number <br /> SUMPS ❑ Distance to nearest: Well e[. r p <br /> Foundation_,��r pro""arty Line /[7 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joa uin county <br /> rules and regulations of the San Joaquin Local Health District. R my ordinances, state laws, and <br /> *. Home owner or licensed agent's signature certifPas the following: "I certify that in the performance of the work for which this <br /> employ any person in such manner as to become subject to workman's compensation permit issued, I shall not <br /> certifies the following: pensation laws of California."Contractor's hiring or sub contracting signature <br /> g: "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 Calif ia.,, <br /> The applicant ust call all r ns ions. Complete drawing on revs side. <br /> �L-d�V <br /> t, Signe L�--�'7 > <br /> i Tithe: Date: /.51 <br /> FO DEPARTMENT USE ONLY <br /> r Application Accepted by Date <br /> Cit rout Inspection by - Date _t84 C <br /> Final Inspection by Date _` <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 95201 <br /> �j <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMI7`NO. <br /> +EH13d41REY.l/e5) -7 n ®� `7/ <br /> 1-$/ <br /> -$ <br /> Ti EH 1428 {C{ <br />