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APPLICATION FOR PERMIT Ipi4YlENT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT RECEIVED <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 J U L 15 199 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED As 76--s <br /> (Complete in Triplicate) .ENVIRONMENTAL HrA-LTH <br /> Application is hereby made to the San Joaquin Local Health District fora PERM]TJS.ERVICES <br /> permit to construct and/or install the work herein described.This application is <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j'��� / n <br /> An4 SS)W feg <br /> / y <br /> Job Address ` • _ P�stfiK / !� /CJ <br /> City Lot Size­ ` �o/-G1 K�PM,�11•J <br /> Owner's Name �l Addressone p J <br /> Contractor YQS Address +!9r License No.X911��� Phone <br /> TYPE OF WELL/PUMP: V NEW WELL 9t WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. f ppOp, LINE 1Q <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 �E y <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p (' _ Specifications pecifications <br /> Q Other ❑ Delta Depth of Grout Seal I n14 <br /> ❑ Irrigation Jq Type of Grout <br /> ---Approx. Depth C1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer Jis <br /> available within 200 feet.] <br /> Installation serve: Residence, Commercial— Other <br /> Number of living unf . Number of bedrooms <br /> Character of sail to a depth of 3 fee . Water fable depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Fo ion Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tota h/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prope e <br /> SEEPAGE PITS ❑ Depth Size <br /> Number \ <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> 1-1 <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 sub-contracting signature <br /> certifies the following: "f 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 applicant m st call for all requir d inspections. Complete drawing on eve►se ide. <br /> Signed ti Title: <br /> Date: <br /> FOR DEPA TMENT USE ONL �p ~ <br /> Application Accepted by / Date O` � Are <br /> Pit or Grout Inspection by Date '` Final Inspection by Date--')~ <br /> Additional Comments: h 4G <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.63$5 <br /> Applicant- Return all copies to:Environmental Health Permit/Servi 160tEr- Hazto�n;Ave P 0 Bax St CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CRECEIVED F!YINFO f�� CADATE PERMiT'NO. <br /> EH13-24fREv.i/851 $7V � �tJ � �� F F �,3' <br /> EH 13-26 !(1!' (/ <br />