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APPLICATION FOR PERMIT , f <br /> r SAN JOAQUIN;LOCAL HEALTH DISTRICT <br /> 1 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> F , <br /> ,:' Telephone (209) 466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED <br /> f . = -(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 �7 City Lot Size PM <br /> I_. <br /> Owner's Name k 1 kn Address L3Z3 Sahone Z U Z / <br /> Contractor AAZUAa5 6LIa Address 13!S2S 100 e , License No._2w_y_g Phone <br /> TYPE OF WELL/PUMP: NEW WELL g WELL REPLACEMENT ❑ DESTRUCTION Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK /10 n P_ SEWER LINES DISPOSAL FLD. d0nP PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom X Manteca Dia, of Well Excavation = Dia. of Well Casing <br /> % Domestic/Private )k Gravel Pack' LlTracy Type of Casing /dye Specifications <br /> ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal 1!m le Type of Grt <br /> ElIrrigation Approx. Depth E3Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 f <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other t <br /> Number of living units: Number of bedrooms w <br /> 1 <br /> Character of soil to a depth of 3 feet: 1 ` "Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to;nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Levh.of lines Total"length/size <br /> FILTER BED ❑ Distance toinearest: Well Foundation Property Line \ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance tolnearest; Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ <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 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 shad employ persons subject to workman's compensa- <br /> tion laws of Calif rnis." <br /> The appli st call for all required ' pections. Complete drawing on revs side. <br /> Signed Title: 2_ Bz 0ba --- Date: -��^F <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by } Date Area <br /> Pit or Grout Inspection by */ Daate Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ L i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: EnvironrTiiental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE I AMOUNT REMITTED CK N RECEIVED BY DATE PERMIT`NO. <br /> 40 ­ <br /> ���777 ,,yy�� ! ^�J �7 <br /> s EH 13-24(REV.1/a 5) �D1 11 q. ci / Q Ci 7 b—7 4 <br /> EH 1426 1 Q .7 `7 <br />