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lo <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 he described This <br /> made in compliance with Sen Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> n is <br /> Local Health District. <br /> Job Address <br /> City—. C� Lot Size� .'�Com✓PM <br /> Owner's Name '. © O N > <br /> Address �� �p.aS-r Phone <br /> - ���_ <br /> Contractor _ U/. Q'et1,S Address­!:�y <br /> Liconse,NJ-VA-- � �f..,s-Ph <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> ti DESTRUCTION U <br /> PUMP INSTALLATION C <br /> SYSTEM REPAIR ❑ OTHER ❑ SD <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> 1 FOUNDATION _ <br /> AGRICULTURE WELL _ OTHER WELL_ _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA J CONSTRUCTION SPECIFICATIONS <br /> Industrial L Open Bottom J Manteca Die:of Well Excavation <br /> L Domestic/Private ❑ Gravel Pack ``�` Dia- of Well Casing <br /> ❑ Tracy Type of Casing_ Specifications <br /> j ❑ Public J Other 17 Delta Depth of Grout Seal - T t <br /> ❑ Irrigation —A Type of Grout <br /> s pprox. Depth ❑ Eastern 5/,Surface Seal installed by i <br /> Repair Work Done ❑ Type of Pump,_ H.P. <br /> Well Destruction L Well Diameter _ — State Work Done- I <br /> D4 Sealing Material(top 50') _ E <br /> Depth—, Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION LJ (No septic system <br /> j - permitted H public sewer is <br /> Installation will serve: Residence- available within 200 feet.) <br /> Commercial_ )Other__ . •�� <br /> r Number bf living units: _ Nu ber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK " t r; —Water table depth <br /> --„O Type/Mfg _ - _^� / . y— Capacity No. Compartments <br /> PIKG. TREATMENT.PLT. L1 i <br /> 1 Method of Disposal _ <br /> Distance to nearest: Well _ Foundatron�_ Pro ' r <br /> ' r' f� per?y.Line <br /> t <br /> L1 ACHING LINE r7 'i <br /> No. & Length of lines <br /> F LTER BED T` Total l�ngthysize_ I <br /> E (� kstance to�nearest: Well, • ' /' <br /> Foundation �J_ property Line—4- <br /> SEEPAGE <br /> SEEPAGE PITS �e tit <br /> SUMPS li p � ' Number "- <br /> r pistance to nearest: Well �r�! <br /> a iK=-+Foundation_ property Line <br /> DISPOSAL PONDS ] t F.- _ F <br /> I�hereby certify that I have prepared this application and that the work'wilt be done in accordance with San Joaquin county <br /> rules and regulations of the Sad Joaquin Local.-Health.District, q MY ordinances, state laws, and <br /> Dome owner or•licansed agent's signature;certifles$ierfollgwincertify that in the 3 <br /> employ any person in such manner as to become subjerit 20iNOrkmane Dorn performance of le wOrk>for Which this permit is issued, I shaft not <br /> certifies therfollowing:"I certify that in the performancee-bf the work for which this per Jaws ss ed,CalI rnia ontractof's hiring or sub-contracting signature <br /> tipn laws of California." v permit is issued,1 shal employ persons subject to workman's COfTlper138- <br /> Ae appli y ust call for all lied rispections. Complete drawing on reverse side. <br /> Signed X - --r- -r-, <br /> t FOR 1115EPARTlVIEIYT USE OlY <br /> Application Accepted by a <br /> Date _ Area q <br /> Pit r Grout Irrupection by Owe -?-._ w._ <br /> - _ Final Inspection by Dat Ll <br /> Additional Comments: <br /> tV Stk 466-6781 ❑ Lodi 369-3621 G Me ca 823-7104 ❑ Tracy <br /> !cant. Return all copies to: Environmental Health Permit entices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO (� CASH RECEIVED SY DATE PERMIT'NO. <br /> SEH 13-21 fREt.i�ec. \ IO T <br /> EH ta2fi J <br />