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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON 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. A -n n n rT <br /> Job Address [@ 1 �.`f�narl.�.# \�rl'A• � City_ Lot Size ftm_o _' _ PM <br /> 5sfa S'' rr` r��r�iALa`(;n1- 1 101 �. (�n6�y1r� ��. -IQ1-55 <br /> G.vJ.eOwrrer+s a e 's"A'ddress Phone <br /> Contrat1 _ / Address `=Q. Q ��A 1 CJWUA License No. LU ` Phone (a - O-, <br /> TYPE OF WELL/PUMP: NEW WELL' ❑ '' WELL REPLACEMENT 0 DESTRUCTION L3 <br /> PUMP INSTALLATION 0 1 SYSTEM REPAIR O OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -;;SEWER LINES DISPOSAL FLO. PROP. LINE y•` ' <br /> `-•' '" ` ` —"bUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS" <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom G-Manteca----- Dia. of Well Excavation Dia...of We�asing f <br /> Domestic/Private .0 Gravel_Pack• ❑Tracy Typo of Casing SPecf6cations !. <br /> ("1 Public 0 Other R��..n Delta Depth of Grout Seal �Type of Grout <br /> I I Irrigation ��prox.,,Depth, I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 TV.. ofsP.ump, H.P. S ate­Work Done— r_ <br /> Well Destruction 0 C'*Well Diameter' Sealing Material (top 5011 <br /> � Cl �Depth le Ma_(erial IBelow•60ae <br /> TYPE OF SEPTIC WORKS NEW INSTALLATION I1 REPAIR_)At)DITIONd DESTRUCTION I I (No septic system permitted if public sewer is 0 <br /> ' ', - ✓ v�-a11 NO within 200 feet.) +• <br /> Installation will serve: Residence `Com Mer�ciab��'�yOt� `Z(Ljt)ZL <br /> Number of living units:_ Number�of(bd�tirboms/ <br /> Character of soil to a depthof-3 Water table depth k ILAO+ <br /> v t <br /> - SEPTIC TANK - ' 0-'Typejfytfg Capacity _ r 'No. Compartments <br /> •PKG.,TRE11 <br /> ATMENT PLT.❑ - T'�"'T' Method of Disposal <br /> Distance to neanfi oundation-- i Property Line <br /> 'L <br /> LLE�'ACHING LINE �'LP Noth.VLengGl linea � ( Total length/size <br /> •-Q F`I'T EWSED BED', ( ❑ DistaricAlo nearest: Well Foundation Property Line <br /> A. <br /> / ' <br /> - SEEPAGi:PITS+ � . . IJ✓Depth r__ Size ���D r NulFber. <br /> SUMPS--i;-- -k';11•Cl�Distaff ce.toJ earest VJelh,, �.'�r# F undation t Ro <br /> Perty Line�— <br /> DISPOSAL PONDS 0 -• ,�� ti <br /> I hereby carfdy that 1 have prepared this,applicationand that the-work will be done in accorda�with San Joaquin county ordinances, state laws. and <br /> rules and regulations of the San Joaquin Local Health'District., �{ -F I <br /> Home owner or licensed agent's.signature certifies the following:."i 2eroty 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 work It's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cerfi ie`s fhe f6ll6Wing:_"I comfy 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 ust call fo 11 re uired inspectiomrComplete-drawingan-reverse\-shid I <br /> Signed X ' Title: `f •y), Date: 11_ ' 1 w�/• r1 1 <br /> FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by T - s DateArea <br /> &or Grout Inspection by yy L a e j�/ Fine�lJlnspection by ate / <br /> Additional Comments: �•.1'�/ f r r F h +•:? <br /> O Stk 466-6781,.__.,_❑ Lodi 369-3621 ❑ Mentena_84-7104 „❑Trecy_8356385 <br /> Applican _ .. <br /> t- Return all coDiea to: Environmental Health Permh/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> NFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED ey DATE PERMIT NO. <br /> •01324IReV.11e51 �� <br /> EH;Cm / 1 6 p cGi �I.3 <br /> I <br />