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r�- <br />' rr <br /> t ' <br /> 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 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. F <br /> SAG�M NTa <br /> Job Address2 ��/�? '��" .:: City ;jmdLot Size PM <br /> Owner's Name H '' f '/C/�Yc'. GL Address {�i� ._,. Phone 7?Y 26 r4 <br /> i <br /> Contractor's Name. /d'1 7" f71f License No. .4 ";S Phone C <br /> TYPE OF WELL/PUMP: k a NEW-WELL�-❑• ", .,h- \ WELL REPL..ACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 0 <br /> ¢ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F ❑ Industrial 19 Open Bottom ❑ Manteca Dia. of Well Excavation t, Dia. of Well Casing <br /> ❑ Domestic/Private " "❑ Gravel Pack—= —❑:Tracy-- Type-of Casing ' Specifications Y.. <br /> ❑ Public �. ❑ Other ❑ Delta 6epth of Grout Seal Type of Grout <br /> ❑ Irrigation 1� _ApproxyDe.pth ❑ Eastern ; Surface Seal Installed by <br /> J, <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well.Destruction .❑ .: Well-Diamete Sealing Material (top <br /> Depth' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i E available within 200 feet.) <br /> Installatio&will serve: Residence� Commercial "`- <br /> ;Number­i f living units: YNumber of_bedrooms._ <br /> gCharacter of,soil to a depth of 3 feet: Water table depth O <br /> SEPTIC TANK ❑ Type/Mfg ;F'/f'.E'/;r;V Capacity_4Z 60. mm No. Compartments � <br /> PKG. TREATMENT PLT. ❑ Method of Disposal !! � <br /> r <br /> Distance to nearest: Well /1610- Foundation tel) Property Line Z f_� <br /> LEACHING LINE No. & Length of lines v=9 0Total length/size 270 <br /> FILTER BED s ❑ Distance to neare • Well_11L Foundation /aZ._— Property Line d-r— , r <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS , ❑ Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ "--` - _y a_x <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. F `" <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> I <br /> The applicant-must•call-for-all-required-inspections: omplete-drawing-on-rerrerse side. - � -- <br /> ��** <br /> Ilk SignedTitle: C.�'s' `s Date: <br /> FOR PARTMENT USE ONLY l <br /> Application Accepted by v`' Date Area i Z <br /> Pit or Grout Inspection by Date Final Inspection by4e Date �6 6 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a26-710,4 / 0-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 INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'N,O(. <br /> + EH 13-24 iREV. 10163E <br /> EH I )- <br /> 1428 - r �l L <br />