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APPLICATION FOR PERMIT „ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heiebv made to the San Jnanurn Local Health District for is permit to construct and/or install the work herein described. This oppMt~r <br /> made in compliance will,San Joaquin Cr,.rnty Ordinance No.549 for sewage or No. 1c62 tot well/pump and the Rules and Regulatiom of the San Jogle^ <br /> Local Health District. <br /> Job Address _ QL�---`/ � /,�� City — lot$4+.3 0 <br /> ` ti'O / ale �.l`/l� one <br /> Owner's Name Address � � � --- Ph.. 5 -IV7 <br /> � 'j ••. <br /> 1 <br /> Contractor Address �,n1r/C� r�-I 1• S/ pfo� 'fi l� d License No. �w / y <br /> ✓/ rPt\OIN <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT CJ DESTRUCTION U f`h <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER 0 <br /> Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE `. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti <br /> O Industrial 0 Open Bottom fl Manteca Ole.of Well Excavation Dia. of Well Coal u r <br /> ❑ Domestic/Private O Gravel Pack I-) Tracy Type of Casw+q__._ Specification <br /> I'1 Public (1 Other I] Delta Depth of Gtout Seal Type of$W '1 <br /> I I litigation __ Approx. Depth I I Eastern Surface Seal Installed by y <br /> Repair Work Oona L] Type of Pump _ H.P, State Work Don Y <br /> 5477 Well Destnx don 0 Well Diameter Sealing Material(top 50') <br /> Depth Filler Material IBeIOw 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IK REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic systemparrr+itted N public sewer is <br /> available within 2t)Q het.► �r <br /> Installation will serve: Residence Commercial_- Othe��� <br /> Number of living units: --/— Number o bedrooms <br /> Character of soil to a depth of 3 feet: _TSsAll 11Wath table depth <br /> SEPTIC TANK Ft' Type IMfg IR e- 0(✓ No.Compartments <br /> Pli TREATMENT PLT.1=1 Method of Disposal 1 <br /> I Distance to nearest: Well of Foundation /0 Property Lkte <br /> s <br /> LEACHING LINE IYNo. 6 Length of lines 0 Total length/ `/� <br /> FILTER BED i 1 Distance to nearest: Well ? / Foundation�s� Property Line 3v, <br /> SEEPAGE PITS 11—"bepth _ .��— Site 3& Number <br /> SUMPS I I Distance to nearest: Well f OU Foundation Property Lin <br /> DISPOSAL PONDS I I y <br /> I hereby certify that I have prepared thi!,application and that the work will be[tore in eceoMsnce with San Joaquin County ordWWWM a,stall leve,and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for wltkh this pem+It Y issued.1"nut t <br /> employ any person in such manner as to become subject to workman's compensation laws of Califomis."Contractors hiring or sub-eont.*CWV sipnahre <br /> certifies the following: "I certify that in the performance of the work for which this pemtit Is ivied,1 shale employ plow subiect to workman's eonpwne- <br /> tion laws of California." <br />.. The applicant must can folAlf rectfillred inspections. Complete drawing on reverse side. <br /> Signed X Title: &4-WCA Date: 7 '/�7 <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> AAplication Accepted by L4 Dote �� h Area <br /> /PJ or Grout Inspection by Dated Feel Inspection by Dab 6c If <br /> Additional Comments: <br /> L-1 Stk 466.6781 O Lodi 3593621 0 Menten 823.7104 O Tracy 836-GM <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.C. Box 2000, Stk.,CA 9=1 <br /> ., <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK 8 RECEIVED By DATE ►[RMIT•NO. <br /> INFO � p CASH <br /> EH 13-24(REV.riasr <br /> EH\I le <br /> r <br />