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APPLICATION FOR PERMIT <br /> a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.� AZEL T ON'AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 y , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- <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 />'l Job Address a/� 9 ./'� w > �S ~CityYrt Lot Size PM <br /> Owner's NAddress /U Phone <br /> Contractor J�, ?/91V S J&?,d F�lddress_; t'WZA!f:?k zE License No.'SVrrd�� Phone 9 2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ W LL REPLACEMENT;' DESTRUCTIO <br /> i TR14 NS FER <br /> 1 PUMP INSTALLATION P$Tn NZ►>v wzU..SYSTEM REPAIR ❑ OTHER ❑ F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEcL..,�, <br /> ! FOUNDATION _..__-,� AGRICULTURE WELL OTHER WELL PITS/SUMPS L _� a <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industriai ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' A0 Dia. of Well Casing <br /> ❑ DomestlC/Private Gravel Pack ❑ Tracy Type of Casing $„F! Specifications f - <br /> � _.r�_.� <br /> Ll Public El Other ❑ Delta Depth of Grout Seal .SD 'r Type of Grout G <br /> ❑ Irrigapprox. Depth ❑ Eastern Surface Seal Installed.by" <br /> Repair Work Done ❑ Type df-Pump H.P. State Work Done f, <br /> Well Destruction I j Well draft—ter �� Sealing Material (top 501 _ GDNc.C'JIF Tom' �_ G <br /> Depth! - ; -!�—Filler-Material.(Below 50'f Shll� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ 'REPAIR/ADDITION ❑ D_ESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_:Other +. <br /> Number of living units: x' Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Wa#er tattle'depih <br /> SEPTIC TANK t ❑) Type/Mfg Capacity No! Compartments <br /> PKG. TREATMENT-PLT. '- "-" "� -, Method,of bisposai <br /> Distance to nearest: Well Foundation Property Line " <br /> ­A <br /> LEACHING LINE ❑ No?& Length of lines ;Total length/size <br /> FILTER BED ❑ Distance to nearest: ;+ Well FoundationProperty Li—e_ <br /> SEEPAGE PITS ❑ Depth j Size F'Number <br /> SUMPS ❑ Distance to nearest: s ' 'WE-II— '-F6U d5bdn A Property Line <br />_- tl]ISPOSAL:PONDS. ❑ <br /> l`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 l `` <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the,workior 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."iContractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in theperformance 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 applical t IoNor ail d inspections. Comp tete drawing on reverse side. <br /> Signed L� A ?�€ Z <br /> Title: Date: <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> # , �Applicati n.Accepted by I � Date �� � Area <br /> Pit or o t Inspection by Date� �6 Final Inspection by ate ld�/ <br /> i r v .' <br /> y � ' <br /> ey <br /> Additio al Comments: r <br /> ❑ Stk `466-6781 ❑ Lodi 369-362 ❑ Man&6823-7104 ❑ Tr cy_835-63fi- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE{ INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0. <br /> + EH 1324(REV.i/e 5) f C� <br /> EH 14-26 <br />