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APPLICATION FOR PERMIT <br /> 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 /> r , f € <br /> Job Address '" 4�-o ;FU-w_ ' 22City (� Lot Size PM <br /> f Owner's Name W+U"rf. '7Lt Ce.14zP�iA'ddress (cb �Ja c�-��. J�5-4t_• - Phone �c �? <br /> (fi <br /> Contractor 1.9 � D� Address e J�� ��"'"'C- �� License No Phone <br /> TYPE OF WELL/PUMP: NEW W -WELL REPLACEMEN DESTRUCTi R <br /> PUMP INSTALLAT SYSTEM R�PAIR ❑ 0TH <br /> DISTANCE TO NEAREST: SEPTIC TANK S1�0 SEWER LINES fGn� DISPOSAL FLO. PROP. LINE /-50 r <br /> FOUNDATION (? AGRICULTURE WELL OTHER WELL O r PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial -2-Open-Bottom`--- -^_tManteca '-Dia-of--Well-Excavation/-Q Dial of Well Casing <br /> Domestic/Private ]Gravel Pack ❑ Tracy Type of Casing t'.$�L -cJ Specifications <br /> ❑ Public Cl Other ❑ Delta Depth of Grout Seal AO Type of Grout LfY ti3_, <br /> I ! irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work-Done` -2' Type of Pump S r c.�- H.P. State Work Done aiz� ,ate <br /> h- m z �� f y , <br /> -'Well Destruction I Well Diameter " / Sealing Material Itop 50'1 <br /> i <br /> Depth 9� Filler Material (Below 50') N <br /> TYPE-OF SEPTIC WORK: -NEW INSTALLATION i.l REPAIR/ADDITION i.I DESTRUCTION I 1 (No.septic system permitted if public sewer iso <br /> available within 200 feet.) <br /> �} r r)_ Ue- e: _ResidenceTCommercial Other <br /> Numberliving <br /> Number of'bedrooms s f <br /> ' Character-of soil to a depth of 3 feet: Water table depth <br /> t SEPTIC TANK ❑ Type/Mfg Capacity + No. Compartmentsi. <br /> PK'G. TREATMENT PLT..❑ Method of Disposal <br /> Distance to nearest:' Welt Foundation Property.Line <br /> LEACHING LINE: ❑ No. & Length of lines Total length} <br /> /size <br /> FILTER HED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I.I Depth Size-e-' I_+^ Number <br /> SUMPS L1 Distance to nearest: Well l "T f"Foundation Property'Line <br /> DISPOSAL PONDS ❑ i <br /> 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 Di1trict. <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 signature <br /> ► certifies the following: "I 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." t <br /> j The applic t.must call for Al required inspections. Complete drawing on reverse side. <br /> 4. Signed Date: <br /> �F••'r <br /> 1 FOR DEPARTMENT USE ONLY <br /> i Application Accepted bybate �$� Vitra— ! Area <br /> r � � ` 4 <br /> k Pit or ICirc/ut Inspection by�_4ZV 9 "411 Date . 1 Final Inspection by Date�zl <br /> r t�� .s1 <br /> Additional Comments: aim, <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, Stk., CA 95241 <br /> i <br /> (NEE AMOUNT DUE AMOUNT-REMITTED In K 0 1 RECEIVED BY PATE PERMIT NO. <br /> WEI <br /> +.EH13-241REV.irns) <br /> EH 14-2e -a o [2YEZ <br />