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1 <br /> APPLICATION FOR PERMIT <br /> J� z <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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.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 �' �a'S T i Ic(10.4/✓ 1 L +A U`-) City� 4 rQ of Size PM <br /> Owner's Name Co -1-0 Address ` — PhoneL- D <br /> Contractor's Name LA} O WPNo. _ Phone afs <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION r SYSTEM REPAIR ❑ ?0�i ERj❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK* __ SEWER LINES `� DISPOSAL FLI� PROP. LINE ( `. <br /> FOUNDATION AGRICULTURE WELL!' rT ~- OTHER WETjot) ' PITS/SUMPS ' <br /> INTENDED USE TYPE"OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC,A��j)I <br /> "o❑ Ind ri `al ❑ Op ottom El Manteca Dia. of Well Excav io � Dia. of Well Casing <br /> estic/Private ravel Pack 1:1 Tracy Type of Casing .S Specifications 117 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal JEO I Ty a of Grout € <br /> ❑ Irrigation --Approx. DepthEastern Surface Seal Installed by cr <br /> Repair Work Done ❑ Type of Pump -50 <br /> H.P. rf State Work Done AJSTA <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 tt <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is" <br /> availablewithin200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other �_ ._ R =6 _• _ _ _ �. <br /> Number of living units: Number of bedrooms <br /> "'"` "'•'Character of soil-to a depth'of 3 feet`" —- - - -•Water table-depth <br /> s <br /> ___SEP_T1C_TANK__.._-❑-T,ypol,Mfg, <br /> PKG. TREATMENT PLT. ❑ u�Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines t ` Total length/size Ul\ <br /> FILTEF BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance�to,,nearest: Well i Foundation Property Line i <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that f have prepared this application and that 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 Ustribt. <br /> Home owner or licensed agent's signature certifies the following:�'l certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such to become subject to workman's:compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I c ify that in he rformance a work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica u call r q in mpl drawingn rse si <br /> tl __ <br /> dge JV P7-- <br /> Signed Title: C�4 �� Dats: �� <br /> ?d <br /> j�7 FOR D RTMENT USE ONLY f <br /> Application Accepted by Date r-30`tfY" Area ✓ <br /> Pit or rout I Gpection by Datp .7 Q -S Final Inspection by Date <br /> Additional Comments: <br />` ' ❑ Stk-466-6781 • --E],Lodi-369-3621 .0-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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEDBY DATE PERMIT•`NO. <br /> INFO CASH <br /> t EH 13-24{REV.101931 M g ND 7-3o--Fs- �,,,a ' <br /> EH 1429 U <br /> i <br /> J <br />