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l APPLICAT,LON FOR PERMIT <br /> SAN JOAQ.uiN,LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZEL T ON`AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> made in compliance with San.Joaquin County Ordinance No.:W for sewage or No. 1862 for well/ and the Rules and Regula 10 of the San J <br /> Local Health District. quin <br /> Job Address �� l City- <br /> —Lot Size. <br /> Owner's Name O11 -r Address <br /> Ph "hem <br /> Contractor Address �S"T�°'l,R4rV 10o� <br /> TYPE OF WELL/PUMP; License No-' <br /> "941 rPhone hQ <br /> NEW WELL ❑ '', WEL.t,REPLACEMENT ❑ DESTRUCTIONS❑ <br /> *, <br /> PUMP INSTALLATION ❑ �'� SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK— OTHER,'Q•' <br /> SEWER LINES./ DISPOSAL FLD. P. LINE <br /> FOUNDATIONAGRICULTURE <br /> OTHER WELL _ ITSt/SUMPS <br /> . <br /> INTENDED USE TYPE DF,W L PROBLEM AAEA C _�• <br /> UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Botto ❑ Manteca pia. of Well Excavation <br /> ❑,Domestic/Private Q GravelPack [,Tracy Type of Casing Dia. of Well Casing <br /> Specifications <br /> ❑ Public ❑,Cit er <br /> a r - E . ,Depth of Grout Seal Type of Grout I <br /> C1 Irrigation � Ajlpto�C. De,pth ; ❑ stern » S c�eiSeal Installed by <br /> Repair Work Done ❑ y. f P,y H* <br /> 1`� , _; State Work Done � I <br /> Well Destruction ❑ Well Dia a er <br /> S.Fr•—•--��_- f 5e'laling Mate�iaf�top-�5U'1--""�"""" <br /> Depth-,= Filler Materia (Below 50'}. <br /> TYPE OF SEPTIC WORK: NEW#1�4TA-L N Q > REPAIR ADDITIO Q DESTRUCTION ❑ (No septic system <br /> ,. ' /. ... � _ I permitted if public sewer is <br /> Installation will serve: F1esid �`''` available within 200 feet.) <br /> rciai ©ther t <br /> Number of living units: I <br /> -_ lymbeof becraSrrrs 1 <br /> Character of soil to a dearth ofd'feet: .k �" <br /> Water table depth - <br /> SEPTIC TANK <br /> M"/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> a DMethod of Disposal <br /> istance to nearest:w �1elL- _ Foundation--=-- ne <br /> 9; <br /> �to%earest: <br /> LEACHING LINE �No & linesFILTER BEp Total length/size❑ Distancell x I <br /> Foundation- oP ttti-1 ine `L t <br /> i -Pr a c/ <br /> i <br /> SEEPAGE PITS <br /> uepth Number <br /> SUMPS D. Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 P <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following- of r <br /> employ any person in such manner as to become subject to workman'srtcomtpensation aws of Cal orniahe Cont actofor rsrh hiring°rpsulrcontractrmit is einglsignaltu�e - a <br /> certifies the fopowino: "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 applicant must call f r a ed insl ctions. Complete drawing on reverse side. <br /> Signe <br /> r�ifrl <br /> title:. . Date: - <br /> /� FOR DEPAR MENT USE ONLY <br /> Application Accepted by 'K\ <br /> r <br /> Date '' Area <br /> Pit r Grout Inspection by Date - rt,P <br /> Final Inspection by <br /> • ��� � Date ; p <br /> Additional Comments: <br />.- ❑ Stk 466-67$1 - - - <br /> ❑ Lodi 369-3621 ❑ Manteca .823-7104 Tracy 835 6385. <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave:;P O .'Box 2009 Stk CA 95201 f # <br /> � <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED HY i GATE PERMIT N0. <br /> + EH 13-24 IpEv.�/a 51 ��• - - � ." � _ �- _ I_ II <br /> EH 14-26 - <br /> � <br />