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I APPLICATION FOR PERMIT O <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1604 E. HAZEL i ON AVE., STOCKTON, CA t d <br /> Telephone (209) 466-6781 s -celve <br /> PERMIT EXPIRES 7'YEAR FROM DATE ISSUED QA EP 1 8 lgi <br /> (Complete in Triplicate) ��� ­IV <br /> 10A9il1AJ COU„� <br /> i, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo Kfilrlr�}�Sc�r�¢'crs�#irs;�gpication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reg%a#fin -of-f0,San Joaquin <br /> Local.Health.District-- <br /> in <br /> • <br /> 4 Job Address C — - of Size PM <br /> f <br /> r Owner's Name A f r ress l jp Sb • Phone 3(.9 Z Y T <br /> I Contractor '”CAddressLicense-moo A S C/4 S't P 219 Qy )Phone 3 6 3 f 3 <br /> o. <br /> kTYPE OF WELL UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q` --OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. *� PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELt PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA~CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation 1t,.• Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-_. - Specifications <br /> M.Public Cl Other 17 Delta Depth of Grout Seal Type of Grout <br /> ! Irrigation »• _.Approx..Depth l.1 Eastern Surface Seal Installed by I, <br /> Repair Work Done ❑ Type of Pump A�R&41 H.P. D State Work Done Y"Zo W <br /> C Well Destruction ❑ Well Diameter Sealing Material (top 50'1 I <br /> ` Depth Filler Material (Below 50'1 <br /> l t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 'REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is I <br /> a r, available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other -4 � . <br /> Number of living units: Number of bedrooms ` <br /> I Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity r.:No. Compartments <br /> [ PKG. TREATMENT PLT.❑ Method of Disposal <br /> r Distance to nearest: Well Foundation Property.Line <br /> l' LEACHING LINE 11 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS I 1 Depth Size Number <br /> _ SUMPS _ D Distance to nearest: - Well Foundation r Property Line <br /> 1 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 /> I Horde owner or licensed agent's signatVxe certifies the following: '7 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 /> I certifies the following: '-i certify that in the performance of the work for which this permit is issued,f shalf employ persons subject to workman's compensa- <br /> II tion laws of California." <br /> The applicant must ca for all required inspections. Complete drawing on reverse side. J <br /> Signed Title: ( .pate: 9 <br /> • <br /> FOR DEPARTMENT USE 91LY <br /> • <br /> Application Accepted by A Data � Area Z— <br /> Pit or Grout Inspection by i Date Final Inspection by atrllt <br /> Additional Comments: ! F <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy SM-6385 <br /> I a Applicant - Return all copies to: Environmentat Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> I <br /> INFO AMOUNT DUE' AMOUNT REMITTED C K RECEIVED BY DATE PERMrT•NO. <br /> +.EH 1344 tnev.„n S. Q2 ys'�o his'—U n �f Y``hh <br /> EH 142E <br />