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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 4613-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> 4 <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 E� � <br /> �3 PN , Its.p� City Lot Size PM <br /> Owner's Name <br /> _4J22 1e0VAWVAddress `� 7ea�j4;tP Ate/ Phone { <br /> t tvNx7 'Z <br /> Contractor IVd49 /q S, Address y.*�n�e�1--�f1 e-42k ??0License No.. Phone <br /> TYPE OF WELL/PUMP: [ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONAO <br /> PUMP INS ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES rf x`" -DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL THEIR WELL PITS/SUMPS _ <br /> INTENDED USE ;TYPE OF!WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia`. of Well Excavation Dia. of Well Casing <br /> .❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasiQg— Specifications <br /> f �� <br /> F] Public M Other F1 Delta Depth of Grorit'S al Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal in"sttalled by / _ <br /> Repair Work Done ❑ Type of Pump H.P. r '.State Work Done �Q�NL�ON &ME-A4.5 <br /> p Q � <br /> Well Destruction J� Well Diameter �5eal-iyLq(Mate{al�lto'p <br /> Depth — 9-70'Fi er6Material'(Below�EQ') fffZI <br /> TYPE OF SEPTIC WORK: 'NEW INSI—Commercial— <br /> At_LATION I I -REPAIR/ADDITION I I 'DESTR CTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installatiori will serve: Residence Other <br /> Number oi-'Iivir7Juniw <br /> Charatter otysoil to a depth of feet: Water table depth <br /> r SEPTIC,TA I K ❑ Ty e/Mlf9 Capacity `"No:Compartments i <br /> PKG. TREATMEf+IT PLT. ❑' Method of Disposal <br /> , 1 <br /> rte' sate Distance to,nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ Nto,:& Length of'lines Total length/size <br /> FILTER BED ❑ Distance to neares;�•,,_ Well - - - Foundation Property Line– 4 - <br /> SEEPAGE PITS l If Depth d Sized_ Number t ' <br /> 1 � I <br /> SUMPS E 1 Distance to nearest: Well�� Foundation Property_11 ine s <br /> DISPOSAL PONDS ❑; <br /> I hereby certify that I have �repared t1 is application and that the wo_ rk will"be-done in sft,r��c ewith San.Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joa bin Local Health District. 1• <br /> Home owner or licensed aggnt's signature certifies the following: "I certify that rn the performance of the work for which this permit jsissued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation IS ws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in.,the.performance-of-the•work•for-rvhich4hr permit-isis'sued,-1 sh-aif employ"Wr0ii-s subTect to workman's compensa- <br /> tion laws of California." <br /> The applicant r requi ctions. Complete drawing on r se e. <br /> - 7 A? <br /> Signed X Title: ate: <br /> r <br /> i FOR DEPARTMENT USE 06Y <br /> to -L � <br /> Application Accepted by Date Area0J� <br /> ,6 <br /> Pit or Grout Inspection by �� � Date Final Inspection by Dater <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ 6di 369-3621-- ❑ Manteca 823;.7104„ ,,.t 0`racy_} 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 16t01 E. Ffazalton Ave., P.6 'Box 2009, Silk., CA 95201 <br /> FEE AHIOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY v DATE PERMIT NO. <br /> INFO <br /> +.EH13-24(REV.r i et 5r <br /> EH 14.28 - <br /> w <br />