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0 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> (� <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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaq <br /> Local Health District. C r�`t D�J <br /> Job Address (_�S/_ __ __._ l�y` fit` _- City�A - Lot Size -­' a r t- PM <br /> Owner's Name ( /L�t° a-y[9 V-, q[Address 1r `Lf. <br /> _-. __._r— Cl_� _5.�: /A[ — Phon& <br /> Contractor(/,J/ le-'-1 IV t9 <br /> IV,!�t��lr Address 1, � i>y`� y a ,11�[License No qq � Phone Q <br /> TYPE OF WELL/PUMP: NEW WELLS- WELL REPLACEMENT CJ DESTRUCTION C' <br /> - PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL Fl-DIS-0 r PROP. LINE 50 � <br /> FOUNDATION -L�� 7 AGRICULTURE WELL OTHER WELL--__-_._- PITS/SUMPS r� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQ(VS_ i <br /> Ll Industrial Wpen Bottom ) Manteca Dia. of Well Exca,v�a+t�ion " ,� Dia. of Well Casing _, <br /> `.Domestic/Private F] Gravel Pack [11 Tracy Type of Casing�lG_�-T Specifications / <br /> i' Public Cl Other f"1 Delta Depth of Grout Seal .. _JQ Type f Gout.i:, 3►� �_ <br /> I Irrigation Approx. De,�pth �? I Eastern Surface Seal Installed by K <br /> Repair Work Done i.] Type of Pump X013— H.P. a..._....._.....__ State Work Dote _-.. <br /> Well Destruction 11 Well Diameter _ Sealing Material (top 5011 ._--............... <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION 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: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ---Water table depth____ <br /> SEPTIC TANK CJ Type/MfgCapacity— No. Compartments <br /> PKG, TREATMENT PLT. I, Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line _ <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance.to nearest: Well. Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS (I Distance to nearest: WellFoundation Property Line <br /> DISPOSAL PONDS L <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a <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 of the work for which this permit is issued, I shall r <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signatr <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compen <br /> tion laws of California." <br /> The applicant m st call for all r. it d inspections. Complete drawing on reverse s' a. <br /> Signed� 1?< _�t.i�2� Title: .:Sep-, e _r' <, _..__ Date: cadlc <br /> `�Af FOR DEPARTMENT USE ONLY Q r <br /> Application Accepted by I - _. _ Date L "'�16-- Area <br /> Pit or Grout Inspection by 71? Date �� Final inspection byDate <br /> Additional Comments: <br /> EJ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE <br /> AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> .-EH 13,24(REV.I/Rel - 'C) <br /> EH 14-26 "7/Aq <br />