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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 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,/ T n `) <br /> Job Address �� PpJAL �J air City N�� Lot Size l�i S / C PM <br /> Owner's Name � le h! h et- 4e.Address C Phone Z d "Ol <br /> L <br /> Contractor 2SSk S CICI Address Z --F Sonam-1 o— Lir�l4s <br /> cense o. Phon� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER % 501 Sta���l�'!�t <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - <br /> [I Public ❑ Other n Delta Depth of Grout Seal 1!S,7 Type of Grout g� <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P._,._- 1.976 <br /> _ - c <br /> Well Destruction ❑ Well - - I .9 7 v <br /> SSK & ASSOCIATES „—to <br /> s <br /> GEOTECHNICAL CONSULTANTS. INC. <br /> t2 <br /> 415-462-4000 19� <br /> 5729-G SONOMA DR. <br /> RCA 84566 <br /> PLEASANTO $ r <br /> VT VLI T <br /> DOLLARS <br /> PAY <br /> TO THE J✓ V!� J /J'�'O <br /> ORDER OF <br /> Ba&�of Ce <br /> pWasanton <br /> 235 <br /> Po. CA 94566 ^ <br /> FOR "�- <br /> ���:.,: accordance with San Joaquin county ordinances, state laws, and <br /> _,a.wture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ....r 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 performancp 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 call for all ragpired inspections. Complete drawing on reverse side. 1 <br /> ! <br /> Signed X -� ICGI4/t---� Title: 9�1<f C� ��Oj :Str(/�C�J Date: Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2109, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE / PERMIT NO. <br /> a.EH13211REV.I/x51 :��V 3�-/) <br /> EH 14.26 <br />