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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> E <br /> /M PERMIT EXPIRES !'YEAR FROM DATE ISSUED <br /> �f (Complete in Triplicate) 1 <br /> t <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 i <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. t ., 1 <br /> / 0 / � • W� } City' Lot Size PM <br /> Job Address 64 II <br /> Owner's Name 1✓,f-� 5 K� K Address Phone <br /> Contractor L-� - ett A' Address LS 0 C-L&A&A icense No. 4]0 Phone / (FA <br /> TYPE OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I` DISTANCE TO NEAREST: SEPTIC 1 ANK ` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E] Industrial ElOpen Bottom LIManteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy type of Casing Specifications <br /> FI Publict ❑ Other r f 1 Delta Depth of Grout Seal Type of Grout __ <br /> I I Irrigation _..Approx. Depth 1.1 Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material (top 501 <br /> E Depth - - - --., rFiller.Material_lBelow_50_I,� — <br /> TYPE OFjSEPTIC WORK: NEW,INSTALLATION I 1 REPAIRIADDITION RUCTION I I tNo septic system permitted it public sewer is <br /> l ICGavailable within 200 feet.) <br /> Installation will serve: Residence_ omOt <br /> _ mercial her . coIN <br /> Number of living units: __Z ,Number of b�edro�om�.s, _ � <br /> Character of soil to a depth of 3 feet-. �� Water table depth <br /> SEPTIC TANKl- - Y[�. ,T.ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ j �. "; Method of Disposal F <br /> Distance to nearest: Well ''"' ' Foundation Property Line <br /> LEACHING LINE i �Isle�&Length of lines Total lenth� _ � �� g !size <br /> FILTER 8ED f ; El 'Distance- to res : Well Foundation__�._C) Property Line <br /> r i f <br /> +F` SEEPAGE PITS { I I Depth -I Size - _ Number - <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I D l <br /> i 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 DiMrict. �., <br /> Home owner or licensed-a nt's sig nature,certifies•the following:l'l-certify-that-in.the.performance of the work for which this permit is issued, I shall not <br /> r emplo any on it su er as to become subject to workman's compensation laws of California."Contractor's hiring,or sub-contracting signature <br /> I certifies _folio certify w in the performance of the work for which this permit is issued,.l shall employ persons subject to workman's compensa <br /> If tion laws of+vaFiforni <br /> Th plicant ust c I r all req 'ed ns,_ ate dr Ing on <br /> Sign Title: date: <br /> r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection Date Final Inspection by Data <br /> Additional Comments: L,-C r Cu Cir I ki h Y- <br /> ­.Applicant <br /> Stk�-466-678t�...- ID-Lodi-369-3621-----O.-Manteca-�-823-7104-��----ElTracy--835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601;E. Haielton.Ave., P.O. Box 2009, Stk., CA 95201 <br /> r v <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO A rr CASH 0-049 <br /> r f •/ <br /> +.EH 13-24(AM 1/95r rl OD � '"t/' � � S� 0 '7--751—04 9 <br /> i EH 14-26 <br />