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t k-ti <br /> %WOI APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. <br /> Job Address A4 7�AQ/J XJ- .4y- J�_ Lot Size ��J /7-/ <br /> L r M <br /> /^� 3 9 - 14193 <br /> Owner's Name /• U itr ti L q��a dclrfess r Phone <br /> Contractor fl4uL IL 50 w'! Address S / f e 10%T T141E¢p)pese No. J9O Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by _ Q� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction F] Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION.b4 DESTRUCTION I I INo septic system permitted if public sewer is c-? <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other oPt--f— 1 7 <br /> Number of living units: Number of bedrooms Jt;L­ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg .! ,�C,apacity No. Compartments <br /> �i. TREATMENT PLT. O �'1!Wi�e 6�lrx.../- �-r f��•o:,. ��SIC'r"^ � Method of Disposal <br /> Distance to nearest: Well >,w Foundation. Property Line 6zevA TioG✓ <br /> VV tfzlOM TriA� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ 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 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."Contractor's hiring or subcontractingsignature <br /> certifies the following: "1 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 applican st call for a equir inspections. Complete drawing on reverse side. <br /> Signed X t�-�- Title: Date: FI <br /> � FOR DE RTMENT USE ONLY Z7 <br /> Application Accepted by IWT Date 105Area <br /> Pit or Grout Inspection by Date Final Inspection by 7-��/ ,���/'Zr..��r"'LtFjate <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DA�.T`EE PERMIT NO. <br /> EH l3N tREy.�rx51 ?' I 1 (� ��/7 '��` l ��(/�� �J(�� <br /> EH 14N VVV V V (((/// YYY CJ <br />