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APPLICATION FOR PERMIT <br /> + SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE_, STOCKTON. CA <br /> -lr Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripiicatej <br /> App#ication Is++e,eby made to the San Jo,,,I , Local Health District for a permit to construct and)of install the work herein described,This application is <br /> made in compliant.with San Joaquin Connty Ordinance No 549 for sewage or No 1862 for well/pump and the Rules and Regulations of the San Joaqu,n <br /> Local Health District. <br /> Job Address >�(�}� W�y Citv�rfd <br /> - _T—---Lot Size���-C�-�� PMC f �/ <br /> Owner's Name-G_,l/, ' UJ-'v <br /> {� {� (1 [�Addre�s]s Phone ({� <br /> Conlra[te� +✓1 1-Cr Address`;0_ laR"tC 7(a� Vt-,�r'ti! ` License No.�a a�.G <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION LJ SYSTEM REPAIR ❑ OTHER Q r , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE '~Ar <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT{DNS <br /> 1.7 Industrial ❑Open Bottom ❑Manteca Dia_of Well E>cavation Dia.of Wer Casing <br /> ri <br /> D Domestic/Private CI Gravel Pack 0 Tracy Type of Casing Specifications <br /> { I Public C1 Other I Delta Depth of Grout Seal Type of Grout <br /> I I Ini .6— __.Approx Depth I I Eastern Surface Seal Installed by _ 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> C—+ Well Destruction - F) Well Diameter Sealing Material(top 501 <br /> F Depth filler Material(Belo�w SB'I _ <br /> -i TYPE OF SEPTIC WORK: NEW INSTALLATION'I I REPAIR DDITION I DESTRUC ION I I (No septic system permitted if public sewer is <br /> {' available within 200 feet.! <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units:I Number of b drooms `7 f_�-'— / <br /> Character of soA to a depth of 3 feet: Water table depth 0 <br /> SEPTIC TANK ❑ Typef Mfg Capacity No.Compartments \ <br /> PKG.TREATMENT PLT_EJ Method of Disposal (� <br /> Distance to nearest: Well__ Foundation Property Line <br /> `i <br /> r ,y <br /> S LEACHING LINE No.&Length of tines — 70 _Zp 'total lenfir ize _ <br /> —! FILTER BED 17_1 Distance to nearest. WellO Foundation 16' Property Lines r <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS I Distance to nearest: Well Foundation Property Line <br /> 4 ( DISPOSAL PONDS Ll <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' <br /> rules and regulations of the San Joaquin Local Health District. „ <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance o1 the work for which this permit is issued,I shall not <br /> 3 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> A canities the following:"I certify that in the performance of the work for which this permit is issued,I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for I re uned inspections.Complete drawing on reverse side. <br /> Signed K Tides V, ` • Date: ._ <br /> r FOR DEPARTMENT USE ONLY <br /> } Application Accepted by Date Tom" Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> S4 ©Stk 466-1 ❑Lodi 369.3621 ❑Manteca 823.7104 ❑�Tracy 835-6385 <br /> Applicant-Return all copies to Environmental Health Perm `Hit/Services 1601 E. azeRon Ave.,P.O.Box 2009,Stk.,CA 95201 <br /> l i (NPO AM,O.rUNT OUE AMOUNT REMI7TE❑ CASH RECEIVED 9Y DATE PERMIT'NO. <br /> EH 1a-7g tl' tJ <br /> Y <br /> ,f <br /> E <br /> 4 { <br /> + I <br /> 4 v. <br /> `I <br />