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gpp� APPLICATION FOR PERMIT • <br /> SAN OAQUIN LOCAL. HEALTH DISTRICT JOAQUIN LOCAL HEALTH DISTRICT <br /> ENVIRONMENTAL HEALTH DIVISIOfa1601 E. HAZELTON AVE., STOCKTON, CA <br /> SPECIAL PERMIT 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 therk her de ri ppl' ation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R eg i oaquin <br /> Local Health District. r <br /> Job Address Z 7P ��_!�/E� J City���.Ik"2W Lot Size PMOwner's Name ±J � , .I_ Cia <br /> I`, i� Address /", �1�����/� -17b/(,-. Phone ��37i7 <br /> Contractors/vA,CJCY_Q7"Wei�4_Address 1914"k-O MA"o 6f License No�70 3 Phone!r 90 <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION x�t' SYSTEM REPAIR E] OTHER ❑ <br /> _2m — <br /> DISTANCE TO NEAREST: SEPTIC TANP_- SEWER LINESZr_4'7?_ DISPOSAL FLD. PROP. LINE ^ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing SMJr.L Specifications <br /> ('I Public jQ Ot/fjQ <br /> thear 1­1 Delta Depth of Grout Seat �Q Type of Grout . <br /> I I Irrigation 9/�Approx. Depth I I Eastern Surface Seal Installed by PAR Mw" _ <br /> Repair Work Done ❑ Type of Pump _�fkd/_ . H.P. — State Work Done _ <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 501 <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 I.7 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. n Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ _ Total length/size \ <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI 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 D13trict. <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 certif 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 muyfca all require sp io omplete drawings reygrse side <br /> SignedX .� 7 Title: K." /'4 Date: _68 <br /> - /nl FOR DEPARTMENT USE ONLY / <br /> Application Accepted by L Y��/l.Gli(I' Date C/_-7 1— FS <br /> Area <br /> Pit or Grout Inspection by {�y��Ty _ DLa�tea � � Final Inspection by Date <br /> Additional Comments: Sc-� ///�.1 a— wCdi'A'a0�iy .0m /�e�ys e- Oro /�fcY�io�77- <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-636 85 <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 I �A RECEIVED BV DATE PERMIT NO. <br /> EH 12-211REV.trest <br /> EH tx-M <br /> _ t <br />