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1 E <br /> APPLICATION FOR` PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicale) <br /> Application is hereby made to the San ,Ina(:uin Local Hew) District for a permit to construct andlot install the work herein described. This app5icaGon is <br /> made in comphunre with San Joarruin Cc unry Ordinancu No, 549 for sewage or No 1862 for well/pump and the Rules and Regularions of the San Joaquin <br /> Local Health DiStlicl. <br /> Job Address _— Sao r raH /r'n� l`Ul4 Cily TR14Gr Lot Size PM <br /> Owner's Name j-T° r_j r �'�1. Address V 'w" Igo,- S[ Phona f D +� 1 -2- 1 g <br /> Contractorkctt Address + '-„ _ -__ -k ._License No. Phone 16 (,..r!'1t <br /> TYPE OF WELL;PUMP: NEW WELL .D WELL REPLACEMENT a DESTRUCTION i- <br /> PUMP INSTALLATION 2, SYSTEM REPAIR LJ OTHER3p OOr'r 't/ S <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br /> �— .FOUNDATION AGRICULTURE WELL MOTHER WELL 3� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _ _ — &,,�wr rr <br /> 1-1 Industrial _ CI Open Bottom G Manteca Dia. of Well Excavation Dia. <br /> F` DomesticlPrivate (-1 Gravel Pack Tracy Type of Casing Specifications <br /> Public F', Other I Delta Depth '�f Grout Seal .__._ _ Type of Grout <br /> Irmlauon Approx. Depth Eastern 5u03ce ,`dual Iniodilud by_�ht/_✓rQ�L 4/i1/G T- <br /> Repair Work Done - Type of Pump H-P. State Work Done <br /> Well Destruction Well Diameter Sealing Material hop 50'1 NEAT G&'�J i1/j G.PCuT' dv S"i>R� <br /> Depth n �L Fillet Material [Below 50'1 �— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I'` DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence — Commercial — Other <br /> Number of living units: . Number of bedrooms _ <br /> Character of sod to a depth of 3 feet: __ ____`—Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE D No.$ Length of lines Total length/size <br /> FILTER BED O Distance to newesc Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ G <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 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: "I 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 must o or all-requ' inspections. Complete drawing on reverse side. <br /> Cs CU�o�/S - �- 9 <br /> Signed X - Title: Date; 3 ZS <br /> /Q:/s a <br /> FOR'DEPARTMENT USE ONLY <br /> Application Accepted by f Date Area <br /> Pit or Grout Inspection by _Date_ _ Final Inspection by_ -_Date <br /> 11 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ^;❑ Mnnteea 1323-7104 <br /> .0 Tiacy &35-&385 r' <br /> i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 951201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH , RECEIVED BY DATE PERMIT NO, <br /> EN 121fREv.r,n5i <br /> EH 14.4-70 AS <br /> / — - <br /> u — , <br /> 0 2-W , <br />