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p <br /> APPLICATION FOR PERMIT .,r) 1 -7 <br /> �3T <br /> 1 a> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> { Telephone (2091 466-6781 <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 describ d. This application is <br /> made in compliance with San Joaquin County Ordinance No.rA9 for sewage or No. 11362 for well/pump and the Rules and Regulatio sof the San Joaquin <br /> Local Health District. <br /> CL,����SdAL� ACA r¢ <br /> Job Address City Lot Sire PM <br /> Owner's Name ___ `1 �J_�C Address 1/6 24 n <br /> Contractor rH I'(J?*k U Address ss S.> CA L S T`ICV/ License No/I"> _Phone ' <br /> TYPE OF WELL;PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM R5PAIR ❑ OTHER <br /> I DISTANCE TO NEgF?EU S,._ EP_1, :: Krr SEWER LINES DISPOSAL FLD. ROP_. LINE <br /> FOUNDATION _ZQ AGRICULTURE WELL Zoo OTHER WELLIs 6 / ITS/SUMPS y <br /> INTENDED USE TYPE OF WELL PR08LEMAREA .CONSTRUCTION SPECIFICATIONS _r; �j~+. <br /> k ❑ Industrial L1 Open Bottom D Manteca Dia- of Well Excavation- Oia of Well Casing. _ C� <br /> I Domestic/Private QY,Gravel Pack ❑ Tracy Type of Casing_ cJ Spi citications <br /> f[i Public I-1 Other fl Delta - Depth of Grout Seal t�LD Qf <br /> I I Irrigation <br /> —.Approx. De h i I Eastern Surface Seal Installed bv. f �' <br /> Repair Work Done 2' Type of <br /> p yp Pum p H.P. _ State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material i8elow 50'1 I c ✓ �+: I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !'I REPAIR/ADDITION t 1 DESTRUCTION : I (No septic-system I iormittedif public sewer is <br /> available.within 200 feet.) I <br /> __�,,lnstallation.will serve:`Residence_ Commercial—. Other ' <br /> Number of hwng units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _L Water table d epth.. <br /> - - <br /> SEPTIC TANK n Type/Mfg-. Capacity__. tNo. Compartments <br /> PKG. TREATMENT PLT. fl <br /> !,Method of Di iposal 1 <br /> Distance to nearest: Well Foundation Property.Line. <br /> LEACHING LINE 17 No. & Length of dines Total length/saes <br /> FILTER 8ED � �' • ��- - <br /> O Distance to nearest: Well __. Foundation _ Property Line j f <br /> r <br /> SEEPAGE PITS I 1 Depth Number L' <br /> 1 <br /> SUMPS Ll Distance to nearest: Well _ Foundation Property Li�ie <br /> DISPOSAL PONDS [-I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin c rnty ordinances, state,laws, and <br /> rules and regulations of the San Joaquin Local Health Di3trict. ' 1--.R —y„_..,,,, .__,�w <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whi& this permit is issued, I shall not { <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractols hi ing or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons ubject to workman's co I <br /> tion laws of California." l r'�nsa- <br /> The applicant mtsl re call for all uinspections,ii <br /> _ q pections. Complete drawing averse side. <br /> Signed X_ � � ilia: <br /> te: <br /> FO,,�k DEPARTMENT USE ONLY <br /> Applicetio Accepted by Date�� Area_ <br /> n ? <br /> b Pit or ro Inspection by to, L. Final Inspection by J� Dates <br /> Additional Comments: Z <br /> G Stk 466-6781 Lodi 369-36210Manteca 7104 Tracy 835-6385 <br /> Q�1 _ <br /> Applicant - Return all copies Environmental Health Per "t/Se ices 1 1, - azalton A e., P.O. Box 2409;j�tk. JGNYt-� rv � <br /> J "f l <br /> FEE <br /> INFO AMOUNT'DUE AMOUNT REMITTED CK <br /> CASH PERRECEIVED BY E MIT'NO. / <br /> u-s <br /> ..EH1324 tREY.t i x 51 <br /> EH 14-20 <br /> ._ <br />