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I y <br /> ' APPLICATION FOR PERMIT <br /> i <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1 + II PERMIT EXPIRES 7'YEAR FROM DATE ISSUED <br /> :F (Complete in TripFcatel <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 wiih San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �^� �..Z./ w (r7/�A/F/U'li a City Lot Size PM <br /> ' Owner's Name <J C-7 � '�'q-syy� Address // - Phone <br /> Contractor s (Address -..Z License Nes+/A�"X�f°"� Phone 00 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> C 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 /> C Industrial ^❑ Open Bottom^'- ;! ❑'Manteca R, Dia.of Well Excavation Dia.of Well Casing <br /> C Domestic/Private _❑Gravel' Peck a .S O Tracy .,f Type of Casing Specifications M Public ❑ Other 4} ❑ Delta Depth ot,Grout Seat Type of Grout <br /> 1t I I Irrigation . __Approxi Depths—1 I Eastern • (Surface Sgal nstalled by <br /> Repair Work Done ❑IN<Type of Pump -H.P: State Work Done_ <br /> ' Well Destruction ❑ Well Diameter Sealing Material It W'1 _ -. <br /> Depth I Filler Material(Below 50,1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION XREPAIR/ADDITION I I DESTRUCTION 1 i Wo septic system permitted if public sewer is <br /> available within 200 feet.) 1- <br /> I Installation will serve: Residence ' <br /> �r/Commercial_+Other <br /> Number of living units: Number of bedrooms� + r <br /> Character of sail to a depth of 3 feet: t Water tab <br /> b depth <br /> SEPTIC TANK ❑ Type/Mfg. (21:W 1y Capacity ^ {(No. Compartments <br /> ' PKC. TREATMENT PLT.❑ 'F�_ Mathod of Disposal <br /> Distance t�nearest: Well!/1� Foundation <br /> _�,Pmpeny Line' <br /> I a <br /> LEACHING LINE `P No. &Length of lines _Z�fW Total length/size <br /> ' FILTER RED ❑ Distance to nearest: Wall Foundation =60perty Line, <br /> SEEP.4E PITS I 1 Depth Size Number <br /> 1 SUMPS ❑ Distance to nearest. Well Foundation Property Line =�-j <br /> ' DISPOSAL PONDS Ela • ''i'`'. Q <br /> I hereby certify that t 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 D3trict. <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 l <br /> ' employ any person in such manner as to become subject to workmen's compensation laws of California."Contractoes hiring or subcontracting 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. T <br /> ff tion laws ul California." <br /> t The applicant must call for al reguir "nspections. Complete drawing on reverse side. <br /> ' 1 - Signed% zv_ ' TiilBi 1�'l Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ' Pit or Grout Inspection byDate Final Inspection by Date �� // <br /> Additional Comments: <br /> ❑Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835.6385 <br /> Applicant-Return all copies to:Environmental Health Permit/Sarvicas 1601 E. Hazelton Ave., P.O. Box 2009, Elk., CA 95201 IE ' <br /> ! INFO I AMOUNT <br /> DUE AMOUNT REMITTED CASH RECEIVEp 6Y DATE PERMIT NO. <br /> "'i.EH Ia24 IREVY,e'51 <br />