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APPLICATION FOR PERMIT <br /> O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZEL 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �r13 n o City Lot Size �� � PM <br /> s <br /> Owner's Name <br /> / f Addresses Phone <br /> Contr ctor Y v Aakc_I Address �a+ License No., -4 Phone 36!t�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMB,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public/'k f 1 Other 7 Delta Depth of Grout Seal �" Type of Grout v <br /> j I I Irrigatipri i Approx. Depth I I Eastern 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 <br /> Depth Filler Material 1 .12 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ REPAIR/ADDITIO E TRUCTION l No septic system permitted if public sewer is I <br /> available within 200 feet.) <br /> 1 Installation Will serve: Residence— Commercial— Other [p) <br /> �kNdmber of living units: . Number of rooms <br /> Character of soil to a depth of 3 feet: Water table depth v f O <br /> SEPTIC TANK I!ItX Type/Mfg Capacity—ALO-0— No. Compartments Z Y G <br /> PKG. TREATMENT PLT: ❑ <br /> + ,RMethod of Disposal <br /> Distance to nearest: h +Well 70 Foundation Property Line <br /> LEACHING LINE11 <br /> # No. & Length of kin.,Q , -Y;l , Total length/size <br /> FILTER BED w ❑ Distance to nearest.' Well`rFoundation�_.._ Property Line ysy <br /> SEEPAGE PITS L I Depth Size Number d 1 <br /> - <br /> SUMPS ❑ Distance.to nearest: Well ',' Foundation Ir6l�Z�roperty,Line 1 7 <br /> DISPOSAL PONDS ' ❑ <br /> I hereby certify that i have prepared this application,ard that the-ayiorOwilLbaA'done in accordance=with_San,Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health.DR;trice. <br /> Home owner or licensed-agent's signature certifies tfie following: "I certify tha`�in�4he perfDrrmanc of the work for which this Perri is issued, I.h II not <br /> employ any person in such manner as to become subject to workman's compersattion-laws of-California %Contractor's hiring-or sub-contracting signature <br /> certifies the following:'I.certify that in the performance of the work for Whlch`this:permit is issued, I shall enmploy-persd6s-subject to workman's compensa- n <br /> tion laws of California. <br /> The applicant ust II for II require ins tions. Complete drawing- <br /> on reverse�sidel y <br /> !, 11 <br /> Signed X Title: Date:'j l f" ��•r/J <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date _���+13 +�{xi Area y <br /> �lt or Grout Inspection bate —� i Final Inspection by Oate <br /> �JV ;+ <br /> """�'+ r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantecti k B23-7104� '" O`T�acy�.835�6385 � ' l <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> rFEE l <br /> INFO AMOUNT DUES AMOUNT REMITTED CASH ;. RECEIVED 8Y j \DgTE PERMIT'NO. <br /> +.EH13-24{REV.ii++sl C70 `1D . uV G ) <br /> EH 14-2e Q •S / �✓ f �'f'�rZ7� '��{O : <br /> w <br />