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APPLICATION FOR PERMIT <br /> -m SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, <br /> C 7 ) OW (Complete In Triplicate) F <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heiein described. Th,�sapplication' is <br /> y' made in compliance with San Joaquin County Ordinance No. W for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.`'"`-` r C' <br /> 4,C <br /> n <br /> Job Address T <br /> .. ` <br /> f ,- - City Lot Size PM <br /> l Owner's Name Aft#ADLUO �tlp _ <br /> S�s Address 'DC7 R.7� - <br /> _ Phone` <br /> Contractor Address � �. /�, ��s'Y" ' <br /> TYPE OF WELL/PUMP: License No. phone �l5�S' <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> f DISTANCE TO NEAREST: SEPTIC TANKOTHEA' .pNt� 1�� <br /> SEWER LINES <br /> FOUNDATION DISPOSAL FLD. PROP. LINE �� <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATI N _ PITS/SUMPS <br /> 173Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Dia. of Well Casing Q <br /> 6-q Gravel Pack Tracy Type of Casing P(�L Specifications <br /> ❑ 03her% '❑ Delta <br /> II�� �, -Depth of Grout Seal _� � Type of Grout �tT <br /> Cl Irrigation l�Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of.Pump. ��� { <br /> H.P. State Work ne <br /> Well Destruction ❑ Well Diam 3er� �� <br /> M41.1�,rlj& ) q Sealing Material {top qq C_t•)yyU3tCy� j�Cti�y�9�y -{� <br /> Depth_ Filler Material (Below <br /> �� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> .Commercial Other <br /> Number of living units: dumber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ CapacityNo. Compartments <br /> Distance t6-nearest: Well <br /> Method of Disposal <br /> Foundation <br /> � Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: Well i. Foundation Property Line <br /> SEEPAGE PITS _ <br /> ❑ Depth Size <br /> SUMPS Number " <br /> ❑ Distance to nearest: Well t <br /> FoundationProperty Line' <br /> DISPOSAL PONDS ❑ <br /> 1 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 cam <br /> certifies the followin I cert that in the rformance of the work for whit his permit issued,/i shall employ Tactors hiring Or sub contracting signature <br /> tion laws of California." p y persons subject to workman's compensa- <br /> The applicantust call for I requi d inspe ions. Complete drawing on reverse side. <br /> Signed 1 D ' <br /> Tit 1pi 6C Date: <br /> TMENT USE ONLY G <br /> Application Accepted b Date /O ` <br /> Are <br /> _ <br /> a <br /> Pit or Grout Inspection by Date ��� <br /> /?r Final inspection by Da <br /> Additional Comments: JJ <br /> ❑ Stk466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac 8366-6385 L 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I gMOUNT DUE AMOUNT REMITTED CK <br /> INFO SFI RECEIVED BY DATE EPERMIT,,NO. <br /> EH 13-24(REV.1/8 5)EH 6-4.28 <br />