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APPL'FCATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone iA) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED <br /> (Complete in Triplicate) " <br /> IL <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 is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address FQ),Q WA ZEp— P D _ City A! Lot Size T PM <br /> Owner's Name kZ#bC-d/ SAAUD iGP AEC '.Address &_Z.r2/ IVIA,4S�eAl7r jVA-y :%;W.0 <br /> Phone i1 <br /> Contractor F(-011 D E>• A'00,A Address /.,,4i rzi e.2 License No. 4�Y74 Phone- 6 <br /> TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP.-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _EOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS .r <br /> INTENDED USE 1? "Tl'FE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing _. . <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casl Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout:Seal Type of Grout <br /> Irrigation ',_Approx.'depth 171 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ 'Type of Pump _. - H.P. State Work Done <br /> WellAestruction i ❑ Well Diameter Sealing Material(top 501 <br /> a ! Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> U / available within 200 feet.) 1 <br /> Installation will serve" Residence_ Commercial v Other b I <br /> Number of living units: Number of bedrooms t <br /> + Character of soil to a de�pt/h pf 3 feet: d" _Water table depth <br /> rSEPTIC TANK J` fid' hype/Mfg L IZit//E S Capacity1 Z�0' No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f Distance to nearest: Well 3 dD Foundation Property Line 14-e <br /> �cav x A <br /> LEACHING.LIN1='�' No. & Length of lines 12--/ BO � _ _ Total length/size Zz <br /> FILTER-BED F ❑ Distance to nearest; 11 foundation ~� Property Line <br /> SEEPAGE PITS ❑ Depth b Size � Number <br /> +SUMPS ?'] L9�Distance to nearest: Well����T Foundation Property Line �- <br /> DI SPOSAL•.PONDS ❑ <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: "I certify that in the performance of the work for which 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."Contractor's hiring 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 subject to workman's compensa- <br /> tion 19vvs of California." <br /> The applicant must call for.all re <br /> Signed uired inspec' s. Complete drawing on reverse side. <br /> r <br /> Title: Date: <br /> f <br /> `?+ FOR DEPART ENT USE ONLY <br /> Application'Accepted by Date1 Area a _ <br /> PR or Grout InspacUSn byZg� Date Final Inspection by D. ^ - L, pa2e b— <br /> Additional Comments: r <br /> ❑ Stk• 466.6781 4 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant-Retum all copies to: Environmental Health Permit/Services 1901 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 <br /> I +} <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT•NO. <br /> + EH t3-24(REV. ^�1� <br /> EH 1426 I <br />