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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ' Telephone (209)4666781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cornplete in Triplicate) <br /> Application is hereby made to the Sen Joaquin Local Health District for a permit W torrtmct and/or Install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.54S for sewage or No.1862 for atll/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /f <br /> Job Add. 14& , /T / /"" " City L� /Cy riog3¢e PM <br /> Otaner's Name t 1 `Z 6 ' d = /'e Address <br /> p^ Y Trt.F' t'f_/Phone <br /> ) (��\ <br /> Contractor's Name ��Efi(P$YC +'•"(��I.Icense No. d.n lur�� �a' !'+ vPAol41-�7�•�S�k VJ� <br /> ,} TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C <br /> - PUMP INSTALLATIGN F. SYSTEM REPAIR C OTHER C \ <br /> DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL__ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑Open Bottom C Manteca Dia.of Well Excavation Da.of Well Casing \� <br /> )a'Domestic/Prlvare 4CG.-avel Pack ❑Tracy Typo of CaaingV � Specifications <br /> C Public ❑ Other C Delta Depth of Grout Seal Tylia of Grout— <br /> `P Irrigation --Approx. Depth C Eastern Surface Seal Installed by '0++ti/ !'t' r L' <br /> JcG <br /> Repair Work Done ❑ Type of Pump H.P.—/—$ State Work Dane <br /> Well Destru,.sicn ❑ Well Diameter Sealing Material(top SOI <br /> Depth—1-95r t Filler Material(Below 601 <br /> TYPE OF SEP-1 IC.YORK: NEW INSTALLATION❑ REPAIR/ADDITION G DESTRUCTION❑ (No septic system permitted R public sewer is "w t <br /> available within 200 feet.) <br /> Installation will some: Residence_ Commerciai_ Other <br /> i Number of living units:_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _. Capacity__ No. Compartments <br /> l <br /> PKC.TREATMENT PLT.G :+Diocese) <br /> Distance to nearest: Well Foundation__ Propertyty Una_ <br /> LEACHING LINE ❑ No. 6 Len lth of lines Total length/size- <br /> --FILTER BED ❑ Distsnce It nearest: Well Four Jatlon Property Line <br /> SEEPAGE PITS ❑ Depth - Sin Number ' <br /> SUMPS ❑ Distance to nearest: Well__ Foundation Property Line <br /> DISPOSAL PONOS rJ <br /> I hereby terrify that I have prepared this a>plication and that the work will be done in accordance with San Joaquin county ordinances,state taws,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."Contracto/s hiring cc sub-contrecting signature <br /> canities the following:"I certify thRt in the performance of tho work for which this permit is issued,I shall emplo,persons subject to vrorkman's compensa- <br /> tion laws aldornis <br /> Tisa a 'cant cast cell for all iret+< rte Complete drawing on reverse side. <br /> Signed q•zCJ 4 ('C' ./ L("Zit ("�,•C2-pN <br /> r T Title: Oats: <br /> U <br /> R DEPARTMENT USE ONLY <br /> ApOT <br /> eeeptetl by 71 — Date_I•.�7•fI9 Arca <br /> Pit or 1! inspection� V Date Final Inspection by E14L AMS Data / <br /> AdditionadCommems: <br /> G Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C Tracy MS-6385 <br /> Applicant-Return all copies to: Environmental Health Pannit/Services 1601 E. Hazelton Ave.. P.O. Box 2OD9,Silk.,CA 96201 <br /> NEO "MOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMR'N0. <br /> EN 14]a � ) tel. HCl ItO.) �—� /Z s!' �7•I\ -a <br />