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APPLICATION FOR PERMIT , A r <br /> N JOAQUIN LOCAL HEALTH DISTRICT IV VLA' <br /> r <br /> 1601 E. HAZELTON FV_` <br /> ON AVE., STOCKTON, CA " , �w r4' <br /> Telephone (209) 466-6781 u j li�� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a. A (Complete in Triplicate) <br /> efai+F <br /> J�� , �n.� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ork hdes�bed.As a pijpc�onJ �J ' <br /> made incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the uses an Regulat'}�sof the an Joaquin <br /> Local Health District.; �� �� 11 . .1,_ �5 l , <br /> ;Aogir � r <br /> x A: ti� <br /> Job Address -Ave City of Size �C✓pY PM <br /> Ad36d <br /> Owner's Name �1Yl�,i e. a'e. — Address P no. ; <br /> Contractor's se-No P_hone-3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION [_1USYBTEM REPAIR ElOTHER ❑ <br /> DISTANCE,TO NEAREST: SEPTIC TANK J SEWER LINES ro� DISPOSAL FLD. 0® PROP. LINE <br /> FOUNDATION AGRICULTURE WELL, /: OTHER WELL •--_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation�(2 _ Dia. of Well Casinb <br /> 9 <br /> X, <br /> Domestic/Private ❑ Gravel Pack ED Tracy Type of Casing - Specifications 1094 <br /> X <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 40 Type of Grout <br /> ❑ Irrigations —S-trApprox. Depth ❑ Eastern Surface Seal Installed by— -5te IA <br /> Repair Work Done ❑ Type of Pump r W.P. State%Work Done g <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L3 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence,— Commercial_ Other <br /> c j <br /> Number of living units: Number of bedrooms (� <br /> Character pf soil to a depth of 3 fe is Water table depth. <br /> SEPTIC TANK ElType/Mfg I Capacity No. Compar3ments <br /> PKG. TREATMENT PLT: ❑ Method of Disposal # <br /> Distance.to nearest: Well Foundation Property Line <br /> LEACHING LINES f .No._& Lengtth'of es*` 1 Total lengthlsize <br /> FILTER BED;. ❑� Distancetosnearesf, . ell Foundation Property Line <br /> _ 5 <br /> SEEPAGE PITS De th "` +'} 4�� - S' <br /> p Size Number '� ` <br /> SUMPS ❑ Distance <br /> I /' tance t neares�R ` ell' #rFoundation Property Line + <br /> DISPOSA Po DS ❑ �, ,,.-A,. 100 f <br /> I-hereby certify that I hav'$-prepared-tP irapplicatiori and that the work wrll'be done in accordance with San Joaquin county ordinances,4f to laws;and--7 <br /> rules and�egulations of the San Joaquin Local Health District. • ] <br /> Home,owner dor 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 r1 <br /> emp`oy any person in such manner as to:bec`ome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> �„""`certifies the following:"I certify that in the'performanee of the work for which this permit is issued, I shall employ persons subject to workma;s compensa- <br /> tio»..laws_of=6alifor�ia:"� �• <br /> The applicants m I for ali d in ctions. rawing on reverse 'de. <br /> t <br /> Signed Title: .__ _ Date: l CI <br /> 10 <br /> FOR DEPARTMENT USE ONLY A r <br /> Application Accepted b /�+ /. ��� �.°/ <br /> pP y Date Area <br /> Pit or Grou nspection by AA DatAl <br /> Final Inspection by Date <br /> 1 17 <br /> Additional Comments: <br /> ❑ Stk 466.6%81 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy x$35-638 ?Ll h6, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box24S, Stk., CA 95201FEE <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO, r <br /> + EH 13-24(REV.101$31 <br /> EH 14-28 <br /> - w <br />