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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. <br /> Job Address/O[ �. y ew d, i C 4P . City �'Q A i•Y Lot Size PM <br /> Owner's Name ex ee. Address 47S Lll, L3.c c TS' 8,13.0 Phone&2 - 63 6-00 <br /> Contractor d%Ieyr f. u/4s Trv.��J-7—cAddress 3 W. M/AeaN 1N. fb)A. 97>At License No.-S7as 68 Phone-24*- f76-.,16Ar <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 14 M�+�»'�"� AA161.4- <br /> DISTANCE TO NEAREST: SEPTIC TANK >aU7 ' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL- PITS/SUMPS �A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 s/ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing pvc Specifications <br /> Ltd S� I /t <br /> f"1 Public jf�Othe�rJM ❑ Delta Depth of Grout Seal d[J Type of Grout <br /> I I krri4��)dT +�y. _.Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Dotte ❑ Type of Pump A2 H.P. State Work pone <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 _ C7 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION I I DESTRUCTION I 1 (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 r <br /> Character of soil to a depth of 3 feet:i Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 -Depth Size Number <br /> SUMPS ❑ Distance to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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: "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 compensation laws of California." 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for ail required in ens. Complete drawing on reverse side. <br /> Signed X ze , Title: �r¢ U c �� Date: �9 n <br /> FOR DEPARTMENT USE ONLY <br /> d <br /> Application Accepted by Date Area 4�3� <br /> Pit or Grout nspection by �Date 0 Final Inspection by _ Date S <br /> Additional Comments: <br /> ❑ Stk 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + Ery 1324(REV.ri95f c <br /> EH 14-28 S to `♦<d —y <br />