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The applican 'red inspe <br />Signed <br />• <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DtSTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />iComplete in Triplicate) <br />Application is heteby 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 arid the Rules and Regulations of the San Joaquin <br />Local Health District. <br />ot <br />Owner's Name ii, a. ...eariff ' el- Address Phone <br />Contractor Iti A 1 (if. r es s 1 ., ,a, . "- — ..f 7 LiCense No./ 2,76,!Phane i i t", <br />TYPE OF WELL/PUM -. NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION L3 <br />f <br />..1 <br />\ <br />PUMP INSTALLATION 0 SYSTEM REPAIR [.7. OTHER El <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .iL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br />D Domestic/Private n Gravel Pack Li Tracy Type of Casing Specifications <br />LI Public LI Other El Delta Depth of Grout Seal Type of Grout <br />I ! Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done t3 Type of Pump H.P. State Work Done . <br />Well Destruction 0 Well Diameter Sealing Material ttop .57i <br />Depth . Material { elow 501 ,Filler <br />TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION DESTRUCTION l i (No septic system permitted if public sewer is <br />available within 200 feet./ <br />Installation will serve: Res'dence i Commercial Other <br />4 <br />t <br />1 <br />S <br />1 <br />Number of living units: Number of bedr <br />t <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK 0 Type/Mfg Capacity No. Compartments ( <br />PKG. TREATMENT PLT. El Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />crACHtNG LI El No. & Length of lines ._....-- -4F-0- Tot4I length/size ( I BED 0 Distance to nearest: We 4---05 Foundation 4. r Property Line <br />SEEPAGE PITS , I Depth g, A joicittre Norther 1;1,-- <br />SUMPS Li Distance to nearest: Well /6"o Foundation 7C9 Property Line AC DISPOSAL PONDS l* 0 <br />I hprphu ,.,-,;r., t k m • I I-•,...A, .....,,....,.......I A.1- n ann tnat the work will be done in accordance with San Joaquin county ordinances, state laws, and 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 subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "l certify that in the perfo of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." <br />CM.Cri.5 Application Accepted by \ <br />Pit or Grout Inspection by <br />A;1 ditional Comments: <br />rl Stk 466-6781 0 Lodi 369-3621 E] Manteca 823-7104 Cl Tracy 835-6385 <br />pplicant - Return all copies to: Environmental Health Permit/SetviceS 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FOR DEPARTMENT USE ONLY <br />Date <br />Date Final Inspection by <br />EH 13-24111SL iii i <br />Lie t4-28 <br />FEE <br />INFO AMOUNT DUE AMOUNT REMITTED <br />... <br />OK 1 <br />CASH RECENED BY DATE PERMIT' NO. <br />`-,-7.--,f7 F7-33o