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APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCACHEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES i-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 Ryles and Regulations of the San Joaquin <br /> Local Health District. � ` � x <br /> Job Address J� f� - � l �`*�dZ f 7ZI7 City _` 5 (L� Lot Size PM <br /> Owner's Name S' A6!/7W.-,?U !'r Address 715 kA,1.4 C+Lam 7 411LJ­e:EPhone — <br /> Contractor f� 7�;Exm cS Address 3 ya X41, fid'/L (-E2—SXC-) License No. Z Phonec-e,— GES 5 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR,❑ OTHER ❑, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> L FOUNDATIONAGRICULTURE WELL F,,. 0THOR-WELE1� PITS/SUMPS i <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM ARl`-_A• , CONSTRUCTION SPECIFICATIONS 04) <br /> ' ❑ Industrial ❑ Open Bottom ❑ Manteca `:Dia'of Well Excavation Dia. of Well Casing 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy "° v Type of Casing Specifications <br /> +.k fl Public.-. ❑ Other A �� � 1 13 Delta- � bepth of Gio'ut Seal � Type of Grout, <br /> . * ❑ Irrigation _ '�Approx,:Depth ❑.Eastern _.. Surface Seal+Installed by {� L <br /> .+ `Repair Work Done ❑ Type of Pump`3 H,P. State Work Done <br /> yWell Destruction ❑ Well Diameter Sealing Material (top 501 t <br /> Depth: Filler Material.(Below 50'). <br /> TYPE OF SEPTIC WORK:.,,NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION ID (No septic system permitted if public sewer is <br /> i 1 � 1. <br /> I--; available within 200 feet.) <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 /> F � <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �' Method of Disposal <br /> k <br /> .- <br /> ' Distance to nearest: Well`i ,5_ R Foundation Property Line i- <br /> LEACHING LINE No. & Length of lines CIL 10 Total length/siz Z, 6 * �- i <br /> FILTER BED! ❑ Distance to nearest: Well^�a Foundation Property Line i <br /> SEEPAGE PITS 1 Depth r Size 41 53 Number C <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS.1 <br /> `�~❑ <br /> 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 regulatiods of the San Joaquin Local Health District. r f <br /> Homeowner or licensed agent's signature certifies the following:."I certify that-in the-perfoftmance 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 Maws 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 laws of California." <br /> The applicant must call for all r uired inspection . C plate drawing on reverse side. <br /> Signed X_ _ �� Title; Date: tel — 71 <br /> r <br /> i FOR DEPARTMENT USE ONLY <br /> f Application Accepted by Date C 1 ^ v Area ..��,� <br /> Pit Grout Inspection by Date Final Inspection by Date� T <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24{REV.1/e 5) --y`,�` Cs'7'"1 q <br /> ! <br /> EH 14-26 /�J -1-S <br />