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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> Job Address ' �/J K City " /]Loot (Size PM <br /> Owner's Name Gt441ee AJ/;O S Address &4ZI a W-44 Phone <br /> Contractor � �`� Address License No. ?_V_4_Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK j't` SEWER LINES -- DISPOSAL FLD. --' PROP. LINE 'S <br /> I <br /> FOUNDATION AGRICULTURE WELL _1- OTHER WELL PITS/SUMPS ,LSD <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d( <br /> ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private }'Gravel Pack ❑ Tracy Type of Casing G Specifications C <br /> FI 1 Public ��(_ F1OOther Delta Depth of Grout Seal Type of Grout <br /> z_A <br /> I I Irrigation 7-OV-Approx. Depth I I Eastern Srr ace Seal Installed by <Ltl?'"Nj F,fo �,✓:_ <br /> Repair Work Done ❑ Type of Pumper H.P. State Work Done <br /> Well Destruction ❑ Well Diameter - — —Sealing-M4rial,_( op 50')- <br /> Depth <br /> 0')-Depth 1 Filler Material (Below 501 .y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> I N _ available within 200 feet.) - -y <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number.of bedrooms 1 <br /> Character of soil to a depth of 3 feet,' ` #d ' _ Water table depth' <br /> SEPTIC TANK ❑ Type/Mfg'` ?` Cap ca ity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / `' ` Method of Disposal <br /> Distance to neare tV+lell- d 'Foundation Property Line <br /> r , <br /> LEACHING LINE 0 No. & Length of-lines '�w " ~" '� Total length/size <br /> ti <br /> FILTER BED ❑ Distance to nearest: Well'•' I Foundation Property Line f1 <br /> SEEPAGE PITS I I Depth '' _ Size _y �- + Number <br /> SUMPS Ll Distancerto n0arest:—I�Ve1f Foundation Property Line <br /> DISPOSAL PONDS ❑ r F—t r"( <br /> -• �- <br /> I hereby certify that I have prepared this application and that the4ork will be'done-irrac_cofdance vfth San Joaquin_county.�ardinances, 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.--1 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 tg.become subject to'workmari's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that 6.fhe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I ! x So <br /> i f <br /> The applicarl ust r quire Complete drawing on raver a side. <br /> Signed X `'-f - 5 Title_ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C Date Area <br /> � <br /> , \.! --,\Pit or Grout Inspection by - [7aie � Final Inspection E �`.`It Date 4� <br /> l���� r � <br /> FF <br /> Additional Commenl1im c 0A, TZ <br /> ❑ Stk 466:6781___ _Ll Lodi_369-3621-. .-❑ Manta .-823-7104-- . -0-Tracy -6385 --V—1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ANO. <br /> +,EH 14-261REV.1iµ51 3l3 f r59—"S. / } <br /> � l <br />