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t APPLICATION FOR PERMIT V � <br /> t <br /> SAN JOAQUIN LOC ' <br /> AL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON CA0 1987 <br /> AIIG <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CNVIROMEN SAL HEALTH <br /> (Complete in Triplicate) kVRMIf/SERVICES, <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ` + 1r`T 0tz4 h i,/ <br /> �/_ �'? �;],, City Lot Size /Z . PM <br /> Owner's Name FFG 1"ar7�'� Address -_r?� !�y 7 95 Pt10 e 7 res cc)3 <br /> Contractor11i Address / E, �: a ��113 <br /> �G <br /> itnse No. Phone <br /> TYPE OF WELL/PU P; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK '` SEWER LINES DISPOSAL FLD.�>� PROP. LINE �/ I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open eott°m ❑ Manteca Dia- of Well Excavation i g S 1 <br /> Dia. of Well Casing <br /> 'Domestic/Private C1 Gravel Pack 71 Tracy Type of Casing Specifications Iof.� <br /> 17 Public f7 Other C] Delta Depth of Grout Seal ! <br /> I I Irrigation A T pe of Grout <br /> —.Approx. Depth I I Eastern Surface Sea! Installed �i�y <br /> Repair Work Done ❑ Type of Pump H p -- <br /> _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Materia! /top 50'} <br /> Depth Filler Material (Below 50') ' f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION t 1 (No septic system permitted if <br /> `''available within 200 feet.) <br /> public sewer is <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: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Ca acit <br /> p Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal { <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED . ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundafion - _ <br /> DISPOSAL PONDS ❑ 15r°party Lme'�'�'�" <br /> I 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 I <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: "1 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 st all for all requi d inspe mplete drawing on reverse side. <br /> Signed X .. <br /> Title: Date: (sy <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection byY <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> 1 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 14-24 iREV,i i rs 51 <br /> :!7�a �t 7 ���EH 14-26 ��J( <br />