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APPLICATION.FOR'PERMIT !9 S r fyy i <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT L� it< til f <br /> 1601 E. HAZE.T ON AVE.,'STOCKTON, CA U <br /> i MAP 8 <br /> Telephone {209}.466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM bATE'ISSUED SAN <br /> T x (Complete in Triplicate) "EA OD�N ®Cq�' <br /> HQ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. his 61306tion 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 , `f— 1.(1 P�CJ'U�! /��! . • City WO&ILot Size *PM [ <br /> Owner's Name Address 532 dtt,P, da k_ Y,9 Phone lu <br /> } <br /> Contractor's Name L1/)i ) �9®a'/3S'—�� ' <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WEtWELL REPLACEMEN DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN00 SEWER LINES,— DISPOSAL FLD. PROP.,.LINE. . <br /> ^T FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing <br /> Domestic/Private Xi Gravel Pack• ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> j <br /> ❑ Irrigation ___Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump l H.P. State Work Done <br /> Well Destruction ❑ Well Diameter l Sealing Material (top 60') 1„ <br /> Depth I Filler Material (Below 501 Wt/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t <br /> available within 200 feet.) <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: I Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity-. No. Compartments <br /> PKG. TREATMENT PLT. ❑ ( Method of Disposal <br /> Distance to nearest: Well Foundation Property Line e <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line D <br /> t <br /> SEEPAGE PITS ❑ .Depth i Size Number <br /> SUMPS -' — '❑ Distance'fo nearest:'-' - Welles 'Foundation ' PropertyLine­ l <br /> DISPOSAL PONDS . ❑ <br /> 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. <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:"I 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 must call for all re qui d inspections. Comple a drawing on reverse sid . , <br /> Signed r Title: Date: 0011-7 ZiF6 _ <br /> F R DEP T ENT USE ONLY IIt <br /> Application Accepted by t Date ere Area <br /> Pit or Grout Inspection by Date J F' al Inspec on by ' pat a t <br /> Additional Comments: 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 I ❑ Manteca 8234104 ❑ Tracy 5 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> �J 1 <br /> FEE } f <br /> INFO AMOUNT DUE AMOUNT REMITTEDCAUR RECEIVED BY DATE PERMIT NO. <br /> + EH 113m244MIM(REV.10/93) cy 'jar <br /> EH 1428 �. Q C7 1%3�s J` <br />