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+ V �. <br /> *` " !I APPLI.CATION,FOR PERMIT <br /> SAN JOAQUIN•LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone'1209} 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, i <br /> Job Address 'YV> City 'C r Lot Size `/.Z _ PM <br /> Owner's Name L(/101 Address Phone <br /> 0 <br /> Contractor u� Address License Phone -15,11 <br /> TYPE OF WELL/PUMP: NEW WELL L1 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom f_1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private C1 Gravel Pack ❑ Tracy ,�' I-Type of'Casinr <br /> Specifications <br /> ❑ Public ❑Other I� O Delta Depth of Grout Seal Type of Grout y �' <br /> "tOArri ation._,,-.. �A <br /> g pproxrDepth'Tfl'Eastern' -'SuTfi'a`ce SciTIn'stalled liy— • 1 ___ <br /> }Repair Work Done d Type of Pump H.P. r S tate Work Done I <br /> Well Destruction ❑ Well Diam'Ler ! Sealing Material/top 50'1 I V\ <br /> Depth �I __- i Filler Material (Below 50'1 l 'V <br /> TYPE OF..SEPTIC WORK: NEW INSTALLATION REPAIR/ADDMON❑ DESTRUCTION EJ (No septic system permitted if public sewer is <br /> ^. available 'thin200 feet) t <br /> Installation will serve: Residence.Commercial_! Other <br /> -- q <br /> Number of Irving units: Number of bedrooms 1 S f I ate\ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O.-Type Mfg a I I �Cepacity_,Ar!V_mZ No. Compartments 41 <br /> PKG. TREATMENT PLT..C' �f�) — Method of Disposal j t <br /> Distance yb neatest: Well % Foundation �t Property Line �j ` <br /> LEACHING LINE ❑ `.No. & Length of lines L����� ` f Total length/size <br /> FILTER BED L_1 'Distance to nearest: Well l vFofdeti ;r,, rty <br /> i ~ <br /> SEEPAGCITS :Litiis`10 �� <br /> L] Depth +� Size._ Number <br /> SUMPS ❑, Distance�to nearest: Well �•. Foundation Property Line__ f <br /> DISPOSAL PONDS U <br /> 1 hereby certify that I have prepared this application and that the work will be dohe in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaqdin Local Health District.. .�t1i <br /> Home owner or licensed agent's signature certifies the following: "I certify that iA 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 cbmpensat'j(in laws'of'C91,�ornia.'''Co'ntractor's hiring or sub-contracting signature <br /> certifies the following:"t certify that in the performance of the Work for which thi§1Serrimit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must:call for all equir .inspections. Complete dilawing on revs sac•side, <br /> Signed.X__ iQi . { TitfB y '^5 - ' Date: <br /> t FOR DEPA01ITMtNT1JSE ONLY I t <br /> Application Accepted by Date r Area L <br /> Pit or Gfout Inspection by Date FingPirispection b _ Date <br /> Additioni l Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - , ❑ Tracy 635-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE_ AMOUNT.DUEl �AMOUN7 REMGTTED :- CK - -p:-RECEIVED l3Y {-=DATE-�K�� 'PERMIT NO- <br /> 'INFO--_ CAS <br /> EH 1324 1REV.I/n 5) �U' 61 .. f 4-3 1 <br /> s EH 14-28, - <br />