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APPLICATION FOR PERMIT <br /> *,w1N JOAQUIN LOCAL HEALTH DISTFmo <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 District. <br /> Jeb Address ={ 4 �i S 1 I 1 IV C A V CityS c aC iz i 0 t�t Size PM <br /> {i. k2C,0 SHiTIf S1. SLkif9105-Q <br /> Owner's Na0101 N S 'z Address 4-FWLAST- N ;F X -7-7002- Pho,.�-(�3 65 G-I ISS <br /> mu" C- S7 Z/15'- <br /> Contractor 1676 RISDDN ROAD Addres License No. z jet Phone "<-66Z3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -3y DISPOSAL FLO.� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 1C PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L` <br /> 0 Industrial ❑9pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private Gravel Pack 0 Tracy Type of Casing Specifications <br /> f-I Public 0 Other ❑ Delta Depth of Grout Seal S Type of Grout C-4EII" x <br /> rgat ipp,�1 /' A rox. Depth I I Eastern Surface Seal Installed b GoAlIY� 2 <br /> X{ `Re it V Y tine — pP P V _ <br /> Repair Work none LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth 730, Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) I <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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING iINE 0 No. & 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 Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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."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 applic7a,40" <br /> nt t13t call for t5- inspections. Complete drawing on re side. rr'' <br /> Signed L Title: Date: _/_a6 A <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7109 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Serv/ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 75201 <br /> NFO AMOUNT DUE AMOUNT REMITFEE TED CASH RECEIVED BY DATE PERMIT'NO. <br /> � EH 13-2111W.r/x v <br /> EH IL <br />