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— - 1 <br /> A <br /> APPLICATION.FOR PERMIT <br /> SAN JOAQUI.N LOCAL.H.EALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,-STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1"YEAR FROMDATEISSUED <br /> {Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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. "' r ^, <br /> 1 7�/- /Vr � i�i��f/I=f �_^� �— City s at Size' ." PM " <br /> Job Address __5 <br /> - <br /> ?� SG f/GaL�F4� _ _ _- <br /> Owner's Name <br /> 3ULAZAff � 04) Address -� Phone " <br /> Contractor Address License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _i.� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (}� <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> 13 Industrial ❑ Open Bottom `❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> V Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> r <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation - Apprax. Depth <br /> �� ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump — H.P. <br /> — _ State Work Gone <br /> Well Destruction , L3Well Diameter Sealing Material {top 50'I <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El. REPAIR/ADDITION LJDESTRUCTION LJ (No septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: ` Water table depth <br /> i <br /> SEPTIC TANK C7 Type/Mfg Capacity— <br /> apaccity No- Compartments <br /> PKG. TREATMENT PL`. ! _' Method of Disposal <br /> I N Distance to nearest:" Well ounbation Property Line <br /> -` gtk oo 1 �" <br /> LEACHING LINE ❑ No: & Lerigth Aines, Total length/size <br /> lstauc`e'to n"earest:�► ~Welly foundation I Property Line <br /> FILTER BED <br /> E <br /> SEEPAGE PITS ~Depth # Size I <br /> Number <br /> S <br /> SUMPS j ❑.._Distance to.nearest: Wel4--�-- -�-Foundation Property Line <br /> DISPOSAL PONDS ❑ . <br /> Thereby certify that I have-prepared this application and that the work will be done in ac 6clance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> l Home owner or licensed agent's signature certifies the%follo6ing: "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 became subject`to w�-skma, s compensation laws of California."Contractor's hiring or sub=contracting signature <br /> certifies the following:"1 certify that in the performance of the work for which this permit isissued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applicant m t call r a requir sir1S ql ions. Complete drawing on rev ide. <br /> Signed Title: Date: <br /> FO DEPARTMENT' USE ONLY <br /> {l � pate •� � Area / <br /> Application Accepted f <br /> 7 9 <br /> ate Final Inspection by Date--�- <br /> Pit or Grout lnspectio s ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑Lodi_W-3621.,. E]-Manteca_823_7a04—d:Tracy <br /> ( Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f ` <br /> FEE CK RECEIVED BY HATE PERMIT NO. <br /> INFO "AMOUNT DUE AMOUNT REMITTED CASH / <br /> + £H 13-24 ME'V.v i A 51 <br /> EH 1428 ....7 •.,--_.- - ._ _ - <br />