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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> (^ 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> I (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.549549 forse`nragee or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address � p 1 so, 4 CwLoAJ. &'U,07, -ep CityFAl$14fJVLPNtot Size /. 96 I4C PMC_ <br /> i <br /> Owner's Name L-. LI EE CNS POY Address . 0 SC-1 7_1u11JA'J Phone <br /> Contractor, — Address License No. Phone <br /> 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> iNTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> a <br /> CI Public t f_l Other Cl Delta Depth of Grout Seal Type of Grout <br /> �. I 1 Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ Y <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> -t Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION [ I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other " <br /> I <br /> Number of living units: —I— Number of bedrooms <br /> Character ofsoil to a depth of 3 feet: E0Water table depth <br /> SEPTIC TANK X Type/Mfg apacity t 2D It'd No. Compartments <br /> PKG. TREATMENT-PLT.0 �17W _ <br /> r Method of'Disposal <br /> Distance to nearest: WelFoundation Property-Line IT <br /> I LEACHING LINE ` No. & Length of lines Total length/size <br /> m <br /> FILTER BED O Distance to nearest: Well - Foundation 1 3y � Property Line s,'� . <br /> SEEPAGE PITS Depth Size Number A <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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." Contractors 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 must call for all r ad inspections. Complete drawing on reverse side. <br /> Signed Title: U'6%ri t/r Date: Z(1,�9 <br /> E ONLY <br />+ Application Accepted by �//lfit.v� 4i� Date 43 Area ro <br /> a S! <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 456-6781 ❑ Lodi 369-3621 0 Manieca 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 /> INFO OUNT DUE AMDUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> EH13-24MEV.1/85) _ �O` rQQf 3_�f p . <br /> J� EH 14-28 <br />