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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> C (,� 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> IAN JOAQUIN LOCAL HEALTH DfSTRI�7 Telephone (209) 466-6781 <br /> ENVIRONMENTAL HEALTH DIVI� TT EXPIRES 1 YEAR FROM DATE ISSUED SE11i�1� D <br /> SPECIAL PEI&1�IIT (Complete in Triplicate) M <br /> ENVIRONMENTA E TH . <br /> Application is hetehy made to the San Joaquin Local Health District for a permit to construct and/or install the wop iT� gFflis appllcaoon Is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1062 for well/pump and the Rules and PR'' 1 bbff��the San Joaquin <br /> Local Health Distrito. 7 <br /> Job Address �' J S-7— :F27 '7+n�ry. ,j <br /> / �}-� /��City i7i✓ir Pzz„ Lo[ Size /'/! r^pN1 <br /> Owner's Name ` �f l!/U_(,(hu� ? p Address !.J V/f., flAI-If 4^"f—-f4 CLri3e Phone !Z J `J I.rl <br /> Contractor/L7 kAG //f Address !��G�0�� License No. Phone��.� O <br /> TYPE OF WELL/PUMP: NEW WELL e.kT WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONAw-- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ZUr- DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ <br /> /INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private P Gravel Pack ❑ Tracy Type of Casing Sr / Specifications / <br /> 1-) Public .fl Othe9Vtdtr`V1?'rfl Delta Depth of Grout Seal Z/y�0 Type of Grout <br /> I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by /L&M±L - <br /> Repair Work Done L] Type of Pump f v80" H.P. . l/—Z State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 A <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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: 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 I I Depth Size__ _ Number <br /> SUMPS IJ 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant muussj,caJ%Vj6rJ all re uire omp late drawing on rreee rse`gide. ) p p <br /> Signed X a//Y////-�'l Title: r/ 0 /.�V/,- <br /> Date: <br /> / FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Q/L( / <br /> Dale 1 T?�_ Area <br /> Pit or Grout Inspection by �yN Date _ Final Inspection by Date <br /> Additional Comments: �u- ✓I G/ 4 �_rr L �/tr ( �J�/I.��y /�� B� Av ve <br /> O 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BV <br /> INFO g DATE PERMIT'NO. <br /> ♦.EH Ia-26IREV.vx51 i ,moi L /�— �!�/ - <br /> EH 14]6 <br />