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f <br /> t <br /> s ' APPLICATION FOR PERMIT �6a� <br /> ti `SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1A x' 1601 E. HAZ.LTON 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. TNs 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. /;I . <br /> ' Job Address 10.3 (/�y�ys.��/!rf/Vl e� r/•f City / 'PM <br /> Owner's Name / / • t4/ upi- Address ' `aS1 hIr10Qr. Phone <br /> �S2 <br /> I p '-77 <br /> Contractor e �s ress� 1r), (3'/f_icense No.lb-Z-3 73 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O7+ DESTRUCTION ❑ <br /> PUMP INSTALLATION ®�-' SYSTEM REPAIR❑ OTHER ❑ <br /> . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL IFLD. PROP. LINE _ <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP r,_ai, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrialt ElOpeh (bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> `❑•Domestic/Private ❑ Gtravel P2ck ❑ Tracy Type of Casing Specifications - <br /> ' In.Publvc,- .�i.'k•. 1 171 Other + ❑ Deltaw Depth of Grout Seal Type of Grout I <br /> �1'I Irrigation- --- ­ MApprox,-D`eeppth I Eastern y <br /> �. S ace Seal Installed b - •- - "y <br /> ._ <br /> Repair Work Done W' Type of Pumpy. H.P. State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Y ' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is G <br /> N tavailable within 200 feet.) U.l <br /> ' Installation will serve: Residence_ Commercial_-,_ Other. <br /> Number of living units" I Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK f '•af ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ '',,t Method of Disposal N <br /> Disumca.to nearest: Well Foundation _Property Line <br /> ' LEACHING LINE ❑ No. 8-L-2ngth of lines Total length/size <br /> I <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line <br /> i <br /> ' SEEPAGE PITS I I Dept Size Size Number <br /> SUMPS ❑ . Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ E <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 /> Home owner or licens ant's signature certifies the folio g: "1 certify that in the performance of the work for which this permit is issued, I shall o <br /> employ any pe m such nor a5 to becom object orkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fo wing: "1 certif hat in t pe f e work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifor 'a.•' <br /> The applici t mu c o all req ' d i mplerawrng on ro de. } <br /> Signed X Title: Date: <br /> f • r t e,`„}}��, �^�"' FO!%1//gamXP`PAAhTMMEENT USEO <br /> - NLY <br /> Application Accepted by r - Oate � / /— � Area <br /> Ph or Grout Inspection by " I Date Final Inspection by �� ate <br /> Additional Comments: <br /> ❑ Stk 4E6fi7B1 O Lodi 369-3621 ❑ Manteca 823-7104 gaTracy�836-6385 <br /> Applicant- Returnall espies to: Environmental Health Permit/Somice_s11601 E.�Hazelton';Ave:, P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT.'DUE — AMOUNT REMITTED CASH 'RECEIVED BY DATE PERM17'NO. <br /> EH 13-24 TREY.1/x x1 <br /> EH II-]a <br /> O O—� <br />