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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT,` <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDr t <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or h stall the work herein described. This application is <br /> made in compliance with San Joaquin County ordinance No.549 for sewage or No- 1852 for well/pump and the Rubs and Regulations of the San Joaquin <br /> Local Health District.` <br /> Job Address 'C /i <br /> ,. ,h(,I'2TY(1 [rot Size pN1 <br /> Owner's Name //<D�EF ' �R� AddressI2_l�0 �/v - 'pLiL/'is:r _ Phone _ <br /> Contracl, }�4! 0.`^'A(�:(1AdtlressOr CLOY 7l9 7 r <V <br /> License No.�7 f�Z �4Rron GS'�S/O <br /> TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT O 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 /> 6 in e ❑Open Bottom ❑ Manteca TDie.of Well Excavation Dia. of Well Casing T <br /> ❑ Domestic/Pr'ivate ❑ Gravel_Pack O Tracy�"r 1_�`Type'ol_Casirig.J� 1 T—'--�Spe,afications_ <br /> ❑ Public �O other ❑ Delta Depth of Grout Seal i Type of Gout - <br /> fl Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by j <br /> Repair Work Done ❑ Type of Pump H.P_. State Work Done _ <br /> Well Destruction ❑ Well Diameter _Sealing Material ([op 507` <br /> Depth_ ler_MeteriaN8e1 .E07_'' I _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (J REPAIR DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is G <br /> available within 200 feet.) <br /> Installatbn witl serve; Residence Commercial __ Other r•' 1 <br /> Number of living units: -/— Number of h 'rooms, / <br /> Character of soil to a depth of 3 feet: •a..f� e"`—� Wtrter[able depth <br /> SEPTIC TANK ❑ Type7Mf t •-'r <br /> 0 "�Celxaciry •'— No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Method <br /> i Property Line! <br /> 1 ' n 1 <br /> LEACHING LINE .Nc. &Length of lines h:� U�0 t t Total bngth/aze__�O <br /> FILTER BED O ry'fSiatence to neereal: NI T�___—FouiWae{ion-1 -'*pFopany'Lnp�J_ <br /> . <br /> SEEPAGE PITS O Depth Sl�a Number X <br /> SUMPS ❑ Disten I ` <br /> _ge to n44rest_.,Wel Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby certify that I have prepared [his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin Local Health District. 1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 1 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> non <br /> certifaws ofies the f ollowi�a'!certify that lin the performance of the work for which this pens[is issued,I shaa employ persons subject to workman's compenss- <br /> The applicantust cab for ell fired inspections. Complete drawing on <br /> X revarsev nnAA p <br /> Signed r <br /> Title: <br /> EPARTMElBT BE ON <br /> Application Accepted by T. Date At" <br /> Pit or Grout Inspection by De[0 First Inspection by Date���Qty I� <br /> Additional Comments: - 1 <br /> ❑ Stk 4866781 ❑ Lodi 368-3621 ❑ Manteca RZ1-7104 ❑Tracy 83663 <br /> Applicant - Return all copies to: Environmental Health Par,rit/Services 1601 E. Ha:ehon Ave., P.D.;Box 2008, SdI CA 9=1 1 <br /> 1l ' <br /> FEE �11 DUE AMOUfy7 REMITTED 1 <br /> INFO CASA RECEIVED By - GATE PFIiMrt'NO. i <br /> Ea,a z.wty.,,es, <br />