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APPLICATION. FOR PERMIT - «. <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a I <br />-� l• 1601 E. HAZELTON AVE., STOCKTON, CA <br /> iTelephone {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 /> aquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Jo <br /> Local,Health.District. <br /> r <br /> PM <br /> Job'Address <br /> .2.3607 � �_ l!"+�S' � City Lot Size <br /> a <br /> T�,,t� II Address Z �GO7 S _ tt "Sw"� v4r� Phone <br /> Owner's Name _ `Cl rI�J}} <br /> p (j Cj - Phone Z <br /> Contractor i-�-i --�'r' r�� Address x 7� C �� License Na. � 7� 67 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> ' f t( L <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t 'h * OTHER WELL= - PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED.USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r Dia. of Well Casing <br /> r L1 indu'strial ❑ Open Bottom © Manteca Dia. of Wel! Excavation g <br /> ❑ DomesticlPnvate C] Grave! Pack, t,,,,a Tracy A Type of Casing Specifications <br /> A" +4rMrwr I R.. .:" w b Type of Grout <br /> i_1 public° (l Qther G I pelta A„ Depth.of Grout Seal - <br /> I I irrigation ll'.Approx. Depth I I Eastern -Surface Seal Installed by <br /> Repair Work Done L) Type of Pump H.P. State Work Done <br /> r Well Destruction Well Diameter L i-%C 5,i ling Material Stop 50'I f <br /> Depth <br /> 2.49 Filler Material (Below 50') f- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I I DESTRUCTION I I availabet+within 200pefeeitled it public sewer is <br /> Installation will serve: Residence; Commercial ! ��Other'' " {� <br /> Number of living units: �� Number of bedrooms J <br /> * ` <br /> Character of soil to a depth'of 3 feet: Water table depth <br /> + Capacity No. Compartments <br /> �'t�SEPTIC�TANK y ❑ I <br /> Type/ fgPIG.TREATMENT PLT. ❑I. . Method of DisposalDistance to nearest: Well Foundation Property Line <br /> n, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ '2 Distanceto nearest: Well F undation Property Line <br /> SEEPAGE PITS, I I �L Depth Size / Number <br /> SUMPS Cl Distance to nearest: Well � Foundation Property Line <br /> I DISPOSAL PONDS ❑ Z . - <br /> I - 1 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 <br /> compensa-tion laws of California." Ila <br /> The applica call all quired inspections. Complete drawing on reverse side. <br /> !I �-- <br /> Signed X Title: Date: [x <br /> EPA RT E T SE ONLY <br /> Application Accepted by ' Date a <br /> f ✓ Ilk Date Final action by ate <br /> Pit or Grout Inspection by <br /> Additional Comments: - <br /> r ❑ Stk 466-6781 ❑ Lodi 369 3621�,rt l� Manteca-823-71040"—L] Tracy 835-6385 y" y <br /> Applicant : Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. <br /> INFO <br /> y <br /> +,EH13-24(REV.i/H5) <br /> EH 14-2a ag <br /> 1 <br />