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Aamw <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . This <br /> madApplicationnompliance with Sanothe San Joaquin County Ordinance NHealth <br /> o.549 for sewage or permit <br /> No. 1862 for well/and/or <br /> pump and the Rules and herein <br /> R Regulations of the Sanapplication <br /> Joaquin <br /> Local Health District. <br /> Job Address <br /> + SS t Tiger City Lot Size PM <br /> p <br /> Owner's Name.S <br /> z,c,�»cNq C-�arr� ddress Phone <br /> Contractor �3h ASag Address /-T�w 6/�y License No. Phone L <br /> TYPE OF WELL/PUMP: NEW WELL 71WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-,--,,-- — ' DISPOS1­1AL FLD, —__,.PROP. LINE <br /> FOUNDATION �� T AGRICULTURE WELL OTHER WELL f PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ElOpen Bottom ElManteca Dia. of Well'-Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications C <br /> FI Public- (-] Other . . . .- 0-Delta Depth Of.Grout Seal_ Type of Grout_ - <br /> /I 'i Irrigation Approx. Depth I I Eastern Surface Seal Installed by - A <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 5011 - _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ; I DESTRUCTION A (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r � <br /> Installation will serve: Residence_ Commercial-k Other <br /> Number of living units: 1 Number of bedrooms <br /> Character of soil to.a depth of 3 feet: -' Wafer tabI6 deplbr, <br /> ' <br /> SEPTIC TANK LQ Type/Mfg A L0� Capacity- «o" No. Compartments L. <br /> �` r <br /> PKG. TREATMENT PLT. ❑ C% Method of Disposal <br /> Distance to nearest: Welles Foundation Property Line <br /> LEACHING LINE f" No. & Length of lines Total length/size 3� <br /> FILTER BED ❑ Distance to nearest: Well Foundation r Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L] Distance to nearest: Well Foundation Property Line <br /> '. DISPOSAL-PONMf S ❑ 1'"- - s <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 Di§trict. <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,1 shall employ persons subiect to workman's compensa- <br /> tion laws of California." ��- <br /> The applicant must call for all required inWttions. Complete drawing on reverse side. <br /> Signed X I> f tV - Title: n Date: •a <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by T Date -1 ? 1 Area 2 <br /> Pit or Grout Inspection by Date Final Inspection-by- - Date <br /> Additional Comme�fs7�ff 'kL <br /> ❑ Stk 466-6781 a ❑ Lodi 11 Manteca 823-7104 ❑ racy 835-6385 712 ep/? <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 9Y " -DATE PERMIT NO. <br /> INFO <br /> EKG <br /> + EH1124(REV.r/ 5 <br /> , -W% <br /> EH 142e '7 )cGh <br />