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VIA APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT =' <br /> 1601 E. HAZE T ON 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.9;49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. fr�/',2 '{/1 /Ja�iv / A/ <br /> Job Address L �`Yv C. (�f City ~ Lot Size- 3t"ewtLuA•PM <br /> Owner's Name _ ah+.a. Address ` t0 ' % Phone R 2-2J <br /> , C ` <br /> Phone -7 Address License No.3 � i p= ,^ <br /> 1p t <br /> TYPE OF WELL/PUMP: . vw u WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <br /> (STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k <br /> ❑ Industria! 00 n Bottom ❑ Manteca Dia_of Well Excavation Dia.of Well Casing <br /> [DDomestic riatevLzlGraveI Pack ❑ Tracy Type of Casing-__ �J C Specifications <br /> ('1 Public n Other n Delta Depth of Grout Seal "®3 ype o ro <br /> r <br /> I ( Irrig ( <br /> ation 0Q_Approx. Depth Irl'Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work one r' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 j e <br /> Depth Filler Material(Below 50') i T, 4 zs <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet) r <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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.L7 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ` <br /> 4 <br /> LEACHING LINE ❑ 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 ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 anyper in such manner as bec a subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the n 'I certify t t i pe mance of the work for is permit i issued,I shall employ persons subject to workman's compensa- <br /> tion laws of <br /> The appli'a st call for,atJ re i dins tions. Complete drawing on re /rise srde,,,iff �i Q•� <br /> Signed X----C = t/ Title: Date: <br /> FOR ENT USE ONLY <br /> Application Accepted by r Date b'��1 Area <br /> Pito Grou Inspection by p to 7� Final Inspectio by Date TV <br /> Additional Comments: �^'O-D e^-•� s T <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑Tracy -6385 e <br /> Applicant- Return all copies to: Environ ental Health Permit/Services 1601 E. Hazehon Ave., P.O. Bo 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO psi RECEIVED BY DATE PERMIT'NO. <br /> ♦ EH 13.24(REV,r w s) <br /> EH 14-28 <br />