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X6f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L '� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address / rf `t' /V e [ V-Al !f/ City S'T�K�� Lot Size PM <br /> IJ ' /, R� –til arf: CALi�= �. <br /> Owner's Name C4 f�1 Q/Z Ky�M Address �16 Z/ (1 C A � `r'I C { 1 �� �A T f <br /> Phone <br /> /f �i �-t woo o <br /> c ? <br /> Contractor i Thi kOSS Address�4ls�o,.yI7y_ ._License No.377 3-rS Phone.SL'yrq7 <br /> Z5 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ F�`f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS =. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation fr? Dia. of Well Casing <br /> s, <br /> ($"Domestic/Private li? Gravel Pack ❑ Tracy Type of Casing Tt '6 pecifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of GroutJ� x <br /> ❑ Irrigation ZLD--Approx. Depth ❑ Eastern Surface Seal Installed by T A o <br /> Repair Work Done ❑ Type of Pump H.P. 1 alp State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 ` <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ (t <br /> C\\�� <br /> Installation will serve: Residence_ Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Y <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. ❑ r Method of Disposal =It <br /> Distance to nearest: Well Foundation Property Line ? <br /> l <br /> j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 <br /> I <br /> SEEPAGE PITS ❑ Depth Size Number f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line I1 <br /> DISPOSAL PONDS ❑ <br /> I 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 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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed ) Title: d�-'� Date: <br /> FOR DEPARTMENT USE ONLY / / } <br /> Application Accepted byDate` / Area <br /> Pit o `Grout Inspection by ate Final Inspection by Date <br /> w: <br /> ditlonal Comments: I <br /> Stk 466 6781 ❑ Lodi 369-3621 w .❑ Manteca 823-7104 ❑ Tracy 835-6385 { <br /> A licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 <br /> :Rs � <br /> FEE <br /> INFO AMOUN DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 1324 iREV.1/85) r�� N V j 0—J t0-0 S--1Z�Oa { <br /> EH 1426 <br />