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APPLICATION FOR;PERMIT <br /> �� SAN JOAOUINiLOCAL:HEALTH DISTRICT <br /> i 1601 E. HAZELTON AVE., STOCKTON, CA <br /> a Telephone (20.9).466-6781 { <br /> `PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ..'(Complete in Triplicate) t <br /> Application is hereby ade to the San Joaquin Local Health Dis ict for a permit to construct and/or install the work herein described. This application is <br /> made in is ane with 5 n JoaquinCoun Ordinance No.549 r sewage or-No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Distr c '? <br /> ,� ..3 <br /> '€ City Lot Size <br /> /—old_ PM <br /> - Job Address <br /> i <br /> - Address • -- ele <br /> 957- <br /> TOwn' e�s Name s <br /> Contiactor's Name License No. Phone <br /> TYPE OF WELL/PUMP:-a..�.. NEW WELL V WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTAi_ti4TI0N_X,,,_ SYSTEM REPAIR ❑� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _stZ_ SEWER LINES^ - DISPOSAL FLD. T� PROP. LINE <br /> FOUNDATION Yom" AGRICULTURE WELL OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ezcavat)on Dia. of Well Casing <br /> 11 <br /> Domestic/Private ❑ Gravel Pack Tracy Type of Casing r Specifications. <br /> ❑ Public ❑ Other ❑ Delta # Depth of GrouttSeal * Type of Grout' . <br /> ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by�, <br /> Repair Work Done ❑ Type of Pump H.Rr, � 9_=S <br /> �r�State Work Done <br /> Well Destruction ❑ Well Diameter Sealifig.Material (top 50'1P , <br /> Depth Miler Material (Below 501 I ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION)< REPAIR/ADDITION ❑ DESTRUCTION ED (No septic system permitted if public sewer is <br /> A - 11.4... 'may. available within 200 feet.) , <br /> Installation will serve: . Residence Commercial <br /> Number of living units: ___L- Number of bedrooms € % <br /> Character of soil to a depth of 3 feet: " - Wate�table depth <br /> � °�'� No. Com artments <br /> SEPTIC TANK ❑ Type/Mfg �h S�_ -SD'N _ Cipacit _ p , , _ <br /> PKG. TREATMENT,PLT. ❑ ' Method of Dis )sal <br /> Distance to nearest: Well Foundation 4 ! Property Line <br /> `r <br /> Z� <br /> LEACHING LINE No. & Length of lines Total length/size -gKFAPZ � <br /> FILTER BED ❑ Distance to nearest: We — Foundation — Property Line` , ) <br /> �l!C(Z <br /> SEEPAGE PITS Depth Size Number <br /> , <br /> SUMPS .Distance to nearest: Well i1�^�'"Foundatlon' -ayPrapeYty-'L ne- yY lex /it r <br /> DISPOSAL PONDS 0 <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 <br /> rules and regulations of the San Joaquin Local Health District. 0 ! <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 �i <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-/i_- <br /> tion <br /> a <br /> tion laws of California." <br /> The applicant scall fvr ail squire inspections. Complete drawing on reverse side. <br /> Signed / p <br /> Title: Date: a <br /> -. <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by. <br /> 4Lk-a Got Inspection by t1 Date�. final Inspection by Date s <br /> .{ <br /> Additional Comments: ' <br /> ❑ Stk 46&6781 ❑ Lodi 369621 ❑ Manteca 823-7104 KTracy 835-6385 <br /> Applicant- "um all copies to: Environmental Health Permit/Services 180 zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> INFO <br /> + EH 13-24{REV.10 . <br /> 183? "� . 1°� <br /> EH 14-26 <br /> i <br />