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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE iON AVE., STOCKTON, CA <br /> Telephone 12091 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r <br /> Job Address CO C) D Gt r4� City_/4 70,A- Lot Size_ L� PM <br /> Owner's Name O CJ it>D l�a� Address Phone <br /> Contractor. ��� � Address. Fp�>! !may License No.a:?,9,-�F JL_M Phone <br /> TYPE OF WELL/PUMP: _ ,. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPANSTALLATION ❑ 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump' H,P. State Work Done <br /> Well Destruction ❑ Well Diameter ' -Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is I- <br /> ' available within 200 feet.) <br /> Installation will serve: Residence.�� Commercial ther <br /> Number of living units: --I— Number of bedrooms 0 <br /> Character of soil to a depth of 3 feet: 1v g A"ry Water table depth _ <br /> SEPTIC TANK ❑ Type/Mfg Capacity �. No. Compartments- - `E <br /> PKG. TREATMENT PLT. 177r- 7 " %`Method of Disposal U <br /> Distance to nearest: Well_/0*1112 Foundation Property-Line G0 <br /> LEACHING LINE No. & Length of lines O Tota l'lengthtsize <br /> LL <br /> FILTER BED O Distance to nearest: Well A" Foundation "Properfp Line <br /> ^� , <br /> SEEPAGE PITS ❑ Depth Size <br /> Number--, -c <br /> SUMPS ❑ Distance to nearest:, Well _Foundation .r` Property Line 1 <br /> DISPOSAL PONDS El ; ` <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 District. <br /> Home owner or licensed agent's signature certifies the following •_ <br /> 9 9 g: "I certiyi 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.Calif ornia.".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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." , ,-i <br /> The applicant must call for all ui spections. Complete drawing on reverse side. i <br /> Signed X Title: - A Date: <br /> r� FOR DEPARTMENT USE ONLY r <br /> Application <br /> P—+EI-telr Afncscpe to.Mb/ <br /> _ 1-3y Area <br /> Milk <br /> � <br /> yDate Finn' Ins <br /> Date��0 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 tk4anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE} INFO AMOUNT DUE --AMOUNT REMITTED° CASH RECEIVED BY DATE PERMITNO. <br /> 5 � EH13-24(AM'ties) in1p0� ^7'A 14-28 v6tCl:5 0 <br />