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APPLICATION FOUR PERMIT 2 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE STOCKTON, CA <br /> �-� u „dd� � s zr�r�� Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �1r�1-'SlPk- <br /> /!l (Complete in Trliplicate) <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 Corr IAWIce with San Joaqum County Ordinance No. 549 for sewage or No. 1862 for well/Pump and the Rules and Regulations of the San Joaquin <br /> Local Heakh District. <br /> Job Address �P City 11C!"i" <br /> Lot Size�1{9C �( f `)C, PM <br /> 1 <br /> Owner's Name 1 C t `L 1ll Ira r'i Address G L' S ;,h L IiS-- ['r !ski `I.''A Phone ( _1 ' -? <br /> Con.ructo: . _ t'_ 1r C Address �11� ���tSAY License No, Phone c'c'' <br /> TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT I=i DESTRUCTION ( i <br /> -� -----^ - _ - PUMP INSTALLATION LJ-"�� SYSTEM REPAIR Ll OTHER r--hl <br />� _ <br /> DISTANCE TO NEAREST: SEPTIC TANK '- 1 SEWER LINES_ zs ! ` DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL( OTHER WELL PITS/SUMPS �r <br /> INTENDED USE TYPE OF WELL ,%PROBLE4,AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom i~I Manteca, Dia. of Well Excavation 1 L' rt N. Dia. of Well Casing <br /> , I <br /> i! Domestic/Private W Gravel Pack 0.Tracy �' Type of Casing S L6 `7 0 P✓ C Specifications <br /> I'! Public fa Other E l Delta Depth of Grout Seal i 1ti s F C Type of Grout L%e r✓l?i�TV'�h <br /> I I Irriu tion S-bLtJ�ppro,. Depth I.I Easter :Surface Saki] Installed by c1(�tet, G7� <br /> PRRepai <br /> r Wort `k'rone [� Type of Pump,/'----" € State Work Done <br /> � H.P. ; <br /> {��� `` - -i <br /> WeH Destruction C] Well Diameter+I Sealing Material It p 501 <br /> Depth j Filler Material (Below 501 _ <br /> TYPE OF \WOFIK:K: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I (No se system permitted it public sewer isav le within 200 feet-) <br /> installatiResidence_ Commercial OtherNumber : Number of bedroomsCharactdepth of 3 feet: 8 f Water table depth <br /> SEPTIC T �f Type/Mfg . Cpacity No. Compartments <br /> PKG. TRE )CI Method o! Disposal <br /> Dis ce to nearest: WeffflE��� Foundation Property Line <br /> , <br /> LEACHING LINE length/size <br /> L1 No. & Leng of lin , g <br /> FILTER BED C1 Distance to n Well Foundation Property Line <br /> SEEPAGE PITS I l `Dia Size Number l <br /> I <br /> SUMPS I.! istance to neares`t:: Well €€ ion Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this-application and that the work will be d6ne in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Heahh District. <br /> Home owner or licensed agent's signature certifies the following: "I certity 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 perit is issued, I shall employ persons subject to workman's <br /> compensa-tion laws of California." I14� <br /> L\tic f <br /> The applicant must call for all quired inspections. Complete drawing-ew-raveree-soda. <br /> Signed X , �[LN, / 159C j�� c�r 1-rl(. Title: f c,'P-T— � ����y o� Date: <br /> FOR DEPARTMENT USE ONLY c <br /> ` Application Accepted by -' """ Date I a Area <br /> Pit or Grout inspection by Data F nal Inspection by Date <br />} Additional Comments: <br />#I C1 Silk 466-6781 D Lodi 369-3621 ❑ Manteca 523-7104 p Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. ElHazelton Ave., P.O. Box 2009, SM., CA 95201 <br /> 1 v..�1.ti }' i r1Z z `1 V`Ows t L-. .�pvo..o¢. • V �✓ f LAS <br /> i FEE AMOUNT DUE AMOUNT REMITTED K 1 � RECEIVED By�j DATE PERMIT NO. <br /> INFO rASH <br />