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r+ <br /> r APPLICATION FOR PERMIT s <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> f ? 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1•YEAR FROM DATE ISSUED { <br /> i <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. I. , F– _ <br /> i $ CU 7 - City -A TkIR0?Lot Size PM <br /> L Job Address 'I .{0 'g' '"' <br /> Owner's Name Address ' �Vtsk Akle Phone <br /> Contractor `a' Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,._ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL.–..TITS/SUMPS _ ---l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t <br /> i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> E ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public 4 ❑ Other C) Delta Depth of Grout Seal Type of Grout <br /> € 1 Irrigation ­Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing-Material...ftop.50') <br /> Depth I Filler Material (Below 50'i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION L) DESTRUCTION 1. INo septic system permitted it.public sewer is .f <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> ,r <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest-. . Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ l <br /> r Number_ <br /> SUMPS Ll Distance to nearest: Well " Foundation Property Line <br /> .-- -,.-+.— +' - ..- ,..�„ 'ice •,-�. .._..._ .�..J-..,"�„-,�. . __ .: .. _.- .. ,,..._ .,.z,.�... <br /> L. - DISPOSAL PONDS <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. <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 lawpofo,".ia," <br /> The apor aI re uired ins tions. Complete drawing on reverse side. <br /> fie <br /> Signed Title: 0ly°&otz:je, Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date�2 -�1ZE7Ar.. 1 <br /> Pit or Grout Inspection by Date Final I pection by Date <br /> Additional Comments: –r r /f <br /> ❑ Stk 466-6781 Lodi 3694621 ❑ Manteca 823-7104 ❑ y 535-6385 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE gMOUNT DUE YOUNT REMITTED ASH RECEIVED BY Dr PERMIT NO. <br /> INFO <br /> +.ERt <br /> t4-28 3.24 <br /> EH (REV.t/n.51 <br /> .-. <br />