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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> 1601 E.HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 4%-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicafiert is hereby made to the San Joaquin Local Haat 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 /> Job Address t V. L o�f! City a I Lot Size pM <br /> Owner's Name_e!f t Address SArtlt' Phone to -5 f E l <br /> I <br /> ^Y Contras tor71.1{{t81 h j"� '��,—p Address License No.i2z-5 Z Phalle-2,�y_ <br /> TYPE OF WELL/PUMP: NEW WELL 6S � WELL REPLACEMENT ❑ CESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER R !(4 Or, t ny <br /> J DISTANCE TO NEAREST: SEPTIC TANK SEWER LIAES DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Or WELL PROW N AREA CONSTRUCTION SPECIFICATIONS <br /> N <br /> ❑Industrial ❑Opr+n Bottom ❑M.Mca Dia,of Well Excavation /o Dia.of Well Casing <br /> ❑Domestic/Private ❑Gravel Pack FJ Tracy Type of Casing Specifications <br /> is Public til Other S�• B• ❑Delta Depth of Grout Seal 36 <br /> ❑Irrigation "'r Type of Grout r e <br /> �Approz. Depth ❑Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 50') <br /> Depth_._ Filler Material(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ ftEPAIRJADDITION❑ DESTRUCTION❑ (No septic system permitter)if public sower is <br /> . ....I available within 200 feet.) <br /> Installation will serve: ,Residence` Commercial_ Other i <br /> Number of living units; Number of Ladrooms I <br /> Charac(er of soil to a depth of 3rfeet: _._� Water,table depth <br /> SEPTIC TANK ❑ Type/Mfg C y_'.;, <br /> �pecity No.Com_pannents <br /> PKG.TREATMENT PLT.-O ._ ---.._._. . .. -.__." Method oI Disposal <br /> Distance to ne�rastl yfdl Foundation Property Line <br /> LEACHING LINE .❑ No.&Length of.lines Total length/size- <br /> FILTER BED ❑ .Distance tgnearast: Well Foundation_ Property Line <br /> SEEPAGE PITS 0 Depth T_Sim Number <br /> SUMPS ❑ Distance to nearostf_J 1 Well Foundation Property Line " <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and slat 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 cartifres the folivving:"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 subieet 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 sut:'act to workman's com <br /> t'on laws of California," pensa- <br /> The applicant Wt tali for ire r coons.Comphto drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> A NT USE ONL <br /> Application Accepted Date - Area <br /> Pit or Groat in c by _: Data- Z Yrs Final-Inspection Data <br /> f 5 <br /> - — - - A aional Comma dA,,--s GLtn �n e <br /> tk 466 6181 ❑Lodi 3-'S-=l ❑ e,, 823-7104 823-7104+ 1:1 Tracy 835 p85 <br /> iAppi!cant=Rertum all copies to:Environmental Health Pamit/Services 1601 E.Hazelton Ave.,P.O.Box 2009 Stk. <br /> " .CA 95201 <br /> 1 <br /> - FEE AMOUNT DUE AMOUNT REMITTED W .-• <br /> INFO J Jy(• C SH - RECEIVED 9Y. DATE PERMR'NQ - - <br /> .EH 1]"1{IREV.t/e 61 / 1 - KV <br /> EH 1418 - - <br />