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.r . <br /> Ir APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.. STOCKTON, CA <br /> Telephone 1209}466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin LoceI Health District for a permit to construct and/or install the work heroin dos�rbod.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Rogl:l..'tions of the San Joaquin <br /> Local Health District. <br /> Job Address ke U16 a"A-Z in, City_�0 ClZ Lot Size PM <br /> if. <br /> Owner's Name Ptianei; Z I $� <br /> f ,< Gddress r <br /> LA <br /> r ti 1 <br /> Contractor P4_ Address_ G License No.2&__ :n� Phone /G � <br /> TYPE OF WELL/PUMP: 3 NEW WELL tV7 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> . f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP._INE <br /> FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS <br /> FENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industria] ElOpen Bottom 0 Manteca Dia.of Well,Excavation—F< r Dia.of WeH Casing <br /> o, ❑ Dometticl Private )�[Gravel Pack ❑Tracy Type of Casing Specifications t <br /> ❑ Public ❑Other ❑ Delta Depth of Grout Seal C. Typo of Grout <br /> �. r 1 <br /> =•F+:T=. ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by <br /> � 5 i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dona <br /> Welt Destruction ❑ Well Diameter ter .� Sealing Material(top 50') <br /> r»; <br /> - MbAdI TFA5 tZell Depth Filler Material(Below 501 t <br /> T F SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION❑ (No septic system permitted if public sewer' <br /> :3z'H available within 200 feet.) <br /> Y• <br /> Installation will se - Residence— Commercial Other <br /> ' Number of living units:__ umber of bedrooms <br /> ` Character of soil to a depth of 3 feet:— r table depth ; <br /> SEPTIC TANK ❑. Type/MfgCapacity No.Compartments <br /> - ., <br /> PKG,TREATMENT PLT.❑ Method of Dispose! I <br /> 1 :�• Distance to nearest: Well s tion Property Line <br /> e <br /> LEACHING LINE ❑ No.&Length of lines length/size <br /> 7 <br /> a FILTER[TED ❑ Distance to st: Well _ Foundation Pro Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMP! ❑ Distance to nearest: Well Foundation Property Line <br /> iSPOSAL PONDS ❑ <br /> I hereby certify that l 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. I k <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 /> �fk°r employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature . <br /> ±,..: <br /> t,>4 certifies the following:N certify that in the performance of the work for which this parntit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> •' The applicant must tali for all r uired inspecs.Complete drawing on reverse side. –tr�pU& fA� tcttd... ; <br /> ` Signed Title: Data: <br /> , vis — 1 E USE ONLY <br /> I Application Accepted by Date y QArea <br /> � 2 �� <br /> x Pit or Grout Date :4`R-9-7Final Inspection by <br /> Additional Comments: <br /> ❑Slk 466-6781- ❑ Lodi 369 3621 ❑Manteca 823-7704 ❑Tracy 835.6385 <br /> Applicant-Rehtm all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave., P.O.Box 2009,Stk.,CA 85201 <br /> FEE <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH RcECC•sssEIVIED+BY DATE +� PERMIT'NO. <br /> �+EH13-241REV,I/a51 - J, ' �J v � 'S �i %�O 2 <br /> # EH W26 <br /> t <br /> 1 <br />