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APPLICATION FOR PERMIT <br /> *..AN JOAQUIN LOCAL HEALTH DISTh./f <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 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 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 Rules and Regulations of the San Joaquin <br /> Local Health Dist"1 rirct. I r— r1 <br /> Job Address Li 4 4 �r`-'i S H I N G A V S City —J C c t Z Odt Size <br /> ...{��-�/Wr,, �1 %2-c+0 S'HtrH S1. S-LtiaFIo 550 PM <br /> Owner's Namely r_ Co. U S 6 Address �[f�uSTr' N F X _71D02_ P�r.�1[3 <br /> 6567�ss <br /> K �- S7 yIS- <br /> Contractor 1676676 RISDDR .0110 Addres License No. z/I2.90 Phone <br /> TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK `" SEWER LINES -3JI DISPOSAL FLD.�_ PROP. LINE 1� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL I�b PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (1 <br /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E) Domestic/Private Gravel Pack ❑ Tracy Type of Casing 'pV�% Specifications <br /> 1-1 Public n Other n Delta Depth of Grout Seal— l M 3 Type of Grout LC'_� t <br /> X`ARe it ori N� _Approx. Depth I I Eastern Surface Seal Installed by <br /> f`Re it ork one Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth - .5 y Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 /> 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING INE O No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL 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 agents 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."Contractors 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 laws of California." <br /> The applicant t call for a inspections. Complete drawing on yrr�v�eerse side. f <br /> Signed X L Title: �'/r� C� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Ph or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> O Stk 466-6781 O Lodi 369-3621 O Manteca 823-7104 O 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 /> ffF!! <br /> EH 1124 IREV.I/M 51 <br /> EH 14X <br />