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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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /� <br /> Job Address i t 2.A0)V1l� /�-C nnmze 'GJ14 City Lot Size 5 A G' PM <br /> Owner's Namecao_ a�, Address S ranY21 a Phone <br /> 3 <br /> Contractor 1QC.L__C',� 34it�s d ss License No. .z>__-Phone9L5eP Zia_ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPL EMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ;K SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f 5b*4-- SEWER LINES I L6 ` +: __ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 64 <br /> ❑ Industrial LJ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> V Domestic/Private f Q Gravel Pack ❑ Tracy Type of Casing Py.c. Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ype of Grout _ <br /> I I Irrigation 2ZrApprox. Depth I 1 Eastern Surface Seal Installed by aLl C _ <br /> Repair Work Done ❑ Type of Pump Sed, H,P. State Work Done <br /> Well Destruction ❑ Well Diameter :_ Sealing Material (top 50') ' <br /> Depth l t4a Filler Material (Below 501 T_7, <br /> �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'11 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 -. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 7 <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 signatugL <br /> certifies the following: "(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 laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: ! Z4 — 9c <br /> =ENT USE ONLY <br /> Application ccepted by� Date Area <br /> Pit u I spection by,L wr `r Dat final Inspection b}T�� ) /� Date ( I <br /> Ad nal Comments: _- f�i�� I" �f Oz/ <br /> Gro �2 � <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. <br /> r.EH 14-21(REV.t/H 5)EH -26 1 <br /> 37/ /��/.QO ']Z '] �f AD ���.. q0 <br /> �-ztg9 <br /> .l <br />