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w 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> l �y n ,,/,0 ] <br /> Job Address `�(/ N J�1N�iLf�-!e+.�� City 5l�(.���/V Lot Size PM <br /> Owner's Name `` <br /> !�'�L�Y COr7Ll� 26Gt1�L�Address J� /V_ :6(h,0410� 141& Phone <br /> Contractor 5 Dpi ddress >�! License No.i'z Phone&E <br /> "TYPE OF WELL/PUMP: ' NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ } <br /> PUMP INSTALLATION SYSTEM REPAIR El OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. LENS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> IST D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> =ivate <br /> aNlI'AZ El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ XGravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public. r ID Other E] Delta Depth of Grout Seal 1504-7rA�-Type of Grout NAfAl' <br /> ❑ Irrigation 4?0–) pprox. Depth ❑ Eastern Surface Sea! Installed by <br /> Repair Work Dane ❑ Type of Pump eLIAM H.P. ) State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501" t^ <br /> Depth Filler Material (Below 501 _ O <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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: } y @ Water table depth <br /> SEPTIC TANK 't ❑ Type/Mfg Capacity _ No.Compartments ' <br /> PKG. TREATMENT PLT. 17a ,, `'� '. �� Method of Disposal <br /> ` Distance to nearest:,M�tgWell Foundation "� Property Line <br /> LEACHING'LINE– ❑ No. &'Length of lines Total length/size ' <br /> i <br /> FILTER BED ❑ Distance"to nearest: .i Well`" � Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well- Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 signatu a 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 o b 'ome subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies th owi : 'I certify a ' he rf-rrnan.of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f Ca <br /> tion .' <br /> The applicant r ui i pectin . Complete drawing on reverse side. <br /> Signed f/!2 <br /> Title: &VbZ1Z4a2517 Date: 2-7 <br /> R EP ENT USE ONLY I <br /> Application Accepted b �/i )3 <br /> Date— Area <br /> Pit or Grout fns ct' by Datex1–Yf� Final Inspection by Date 's <br /> Additional Comment <br /> ❑ Stk 466-6781 VLodi 36T&620r ❑ Manteca 823-7104 Tracy 83&63f5 �i <br /> Applicant- Return all copies to: En 'onmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .d <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVEp_BY. _ DATE., _ PERMIT"NO. <br /> INFO �/J <br /> + EH 11241REV. /a 5) 7' a'�� A; <br /> y It �_C 4 1 I ) <br /> EH 10.16 T/ � O f] CN 0 I� .3 <br /> g.s �S E <br />