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I <br /> ' APPLICATION.FOR PERMIT <br /> .g SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,.STOCKTON, CA <br /> I -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> .$ (Complete in Triplicate) „h, <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 /> e" -� •�k, �,.. - Res r. ''i::,-�. . . <br /> a L <br /> Job Address �� ��� City_51!; G o't Size PM <br /> k Owner's Name q Address Phone 3 <br /> I Contractor /�'!/9ef~Address License No.—Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Jed'/j)ZPAA1.-�,-,A► •TEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.,SEPTIC TANK 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> UVDomestic/Private ❑ GravellPack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other` ❑ :Delta Depth of Grout Seal Type of Grout <br /> ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by r <br /> Repair Work Done ❑ Type of Pump S'U P,_ H.P. _ _- State Work Donej21!5F15,g!F�T"> <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') � /L/_� /wz/ /2Ci'LX�e. <br /> Depth Filler Material (Below 501 - <br /> ` U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence L Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ Water table depth C� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> x <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> k Distance to nearest: Well Foundation Property Line <br /> I jI <br /> LEACHING LINE ElNo. &[iLength of lines l A�:ti inx Total length/size <br /> FILTER BED ❑ Distance to nearest: Y Well Foundation Property Line <br /> � II <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS-. ❑PONDS [I Distance to nearest: �eTln -- <br /> - Foundatio - Property Line <br /> DISPOSAL <br /> SUMP - ' <br /> f l <br /> I hereby certify that 1 have pre ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ' rules and regulatidnsrof lthe'Sln Joaquin Local Health),District— �� A1 <br /> Home owner or licensed agerj't's signature certifies the following: "I certify that in tNe 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 signature <br /> certifies the following:"I certify that iA the performance of the warkfor-which-this.permit.is•issE�-,-4-shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu c I r a re ui�Id inspections. Complete dra�ing dn,reveQe ide. <br /> Signed X Title:"".� ,^/:�- Date: <br /> _ `�-� _3FOR DE IAirMkNf)ISE ONLY '� C--� <br /> Application Accepted by ' -r Oat-, <br /> �A i. <br /> Pit or Grout Inspection by 'bate Final Inspection by Date,-� <br /> 'J""Additiorial'comments: T-'- 9Q M <br /> �M G <br /> ❑ Stk 466-6781 ❑ 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, Silk., CA 95201 ,,,;, <br /> t.- <br /> FEEu �,rCK . . t ti . .•\ <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. <br /> + EH 13-24 <br /> EH 1428[F1EV.1/H 51 /(Q 'b <br />