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4' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r * <br /> Job Address Q GZD City �'j�0_4Lot Size PM <br /> I <br /> Owner's NameAddress +�/ E •1, ,okEvs4AA Phone <br /> Contractor -,�• �� /` ��N':! Address �0. � �/ /Yj /� Y License No ?Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL--- OTHER WELL PITS/SUMPS t <br /> it <br /> I <br /> USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS �- <br /> INTENDED - fF. <br /> Ma— <br /> Ll Industrial ❑ Open Bottom ❑ nteca' bio. of Well Excavation Dia. of-,Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack /1r,0 Tracy, ro=.>Type of Casing Specifications <br /> f'l Public ❑ Other i Cl Delta Depth of Grout Seal Tlype:of.Grout _ <br /> I I Irrigation --Approx. Depth I l I Eastern Surface Seal Installed'by' I _ <br /> Repair Work Done ❑ Type of Pump '�) H,P. State Work Done — t <br /> Well,Destruction ❑ Well Diameter Sealing Material {top 50'I +: ~•} <br /> Depth c Filler Material (Below 50'.) •:� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION DESTRUCTION'i,I (No septic system permitted if public sewrer,is -a <br /> ( available within,;40 feet.?) I (� <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: _J— Number of,bedrooms <br /> Character of soil to a depth of 3 feet:' ��l3ir/� 1/' �dV°r/�'�, "®.�" � Water table,depth <br /> SEPTIC TANK ❑ Type/.Mfg. <br /> '+� NoiCompartsi,'entsL'�"w``'' <br /> PKG. TREATMENT PLT. ❑ - Method ofr4isposal <br /> # Distance to nearest: Wel Foundation' Prope'riy Line <br /> _... F _ I <br /> LEACHING UNE r i No. & Length of lines _ ��GDf r "' Total length/size 6 )d=t <br /> FILTER BED ❑ Distance to nearest: Well Foundation!f!2137—~ Property Line 's! <br /> SEEPAGE PITS l I Depth Size. _ Numberr A <br /> SUMPS CI Distance to nearest: Well Foundation Property'`Lihe `` ' '� <br /> DISPOSAL PONDS ❑ `=•-I •-z � !1 <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 r' <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 foe which thWvermit is issued,.) shall not (� <br /> employ any person in such manner as to become subject to workman's compensation laws of Ca�lifornia..'.'...Contractor's-hiring Zo sub-ceritracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issudd, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i c <br /> Theiapplicant must call for 11 re fired inspections. Complete drawing on reverse side. <br /> i <br /> Signed X Title: Date: �� <br /> FO EPARTMENT USE ONLY # <br /> Application Accepted by Date le Area <br /> Pit or Grout Inspection by Date Final Inspection by" Dat <br /> Additional Comments: { <br /> ❑ S1k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' <br /> r 7 EE AMOUNT'DUE.;' i'. .j.AMOUNT REMITTED ' ') gEGEIVEDgd3Y'. DATE PERMIT NO. _._ ..,- <br /> _ INFO. �. - ..CASH"I - = -- - -- - - - <br />' <br /> EH 14-28 <br />