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Y* K'• <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.-HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> the San Joaquin Local Health District for permit to construct and/or install the work herein described. This application is <br /> Application is heieb made to q <br /> pp Y <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> 2 I LI 11 (�,�j` �+f 1� kc� City R �� Lot Size �caes PM <br /> p^1- �f ' �/� <br /> Owner's Name -3ACk ` 91� L"'We4 Address Phone <br /> Contractor <br /> ( Address SO `f �AJ AVS icense No. 2q-39/15 Phone 8-2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 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 <br /> ❑ Industrial ❑ Open Bdtiom' 171,Manteca Dia. of.Well,Ezcavafion'' Dia. of Well Casing <br /> ❑ Domestic/Private ❑-Gravel-Pack---�---❑ Tracy—------- ,Type of-Casing. Specifications <br /> t - <br /> i f'1 Public n Other F1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation __Approxi Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done L1 Type of Pump H.'P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth 1 y Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR4-A•90ITION V DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence �!{ Commercial }_"40ther i <br /> !Number of living units: —I-- Number of bedropms <br /> � d <br /> Character of soil to a depth of 3 feet:r A` Water table depth <br /> p <br /> I SEPTIC TANK ❑""T9p­e/N4f5 "" - - ;' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ � K, Method of Disposal <br /> Distance to nearest: "Well e- Foundation Property Line <br /> I LEACHING LINE L�No. & Length of lines Total length/size 70 <br /> I FILTER BED ❑ Distancerto nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑' Distance Ito nearest: Well Foundation Property Line Y <br />. DISPOSAL PONDS t ❑ �.. <br /> I hereby certify that I have prepared this application and that the work will be do ne.in accordaiice with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the"San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance ofithe work for which this permit is issued, I shall not <br /> employ any person in such manner as to b oma subject to workman's compensation laws of_California." Contractor's hiring or sub-contracting signature <br /> i certifies the following: "i,-dertify that in the rformanae of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California."- ° { <br /> r r <br /> The.appiican all for 907equired in ctions. Complete drawing on reverse side. <br /> r Signed X 11"0'0110,11Title- --�-� _�e Date: 2� � <br /> DEPAiiaVIENT USE N Y <br /> I Application Accepted bY_ Date _' Area <br /> _ P <br /> Pit.or Grout inspection by # Date .Final Inspection by � Data <br /> Additional Comments:! <br /> ❑ Stk 466-6781 1 ❑ Lodi 3694621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> _..,.,..Applicant Return-all-bopiei w-Environmental-Health-Permit/Service -1601ME.-Hazelton Ave'—P.O-Box"2009-Stk—CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE f,;AMOUNT REMITTE6.-f—]Z�W 1 t RECEIVED BY I DATE PERMIT'NO. <br /> 4 + EH 13.24 IREV,t i n sl - <br /> 0 <br /> I. EH 14-26 <br /> I � - <br />