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APPLICATION FOR PERMIT yy�� <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E�-HAZEL•TrOkAUE:;,STOCKTON, CA f <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES,1 YEAR FROM DATE ISSUED 2 r <br /> (Complete in Triplicate) ���wl✓�.^.,. `', <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wd`tk,here1"'descrbed 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�fegulatibns 8f the San Joaquin <br /> Local`Health District; <br /> 1�01_a(,.. ,�i,l <br /> - �r <br /> Job Address <br /> Size PM <br /> Owner's ame Zue-ke. Address <br /> Phone <br /> Contract r. GtWI Address Z <br /> License No.IDI" Phone 6 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION p'�., � <br /> I�E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '} , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L1NES DISPOSAL FLD.�X, <br /> PROP. LINE .1 x <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSJSUMPS ) ' f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation j <br /> ❑ Domestic/Private ❑ Gravel Pack �J Dia. Caging a <br /> p. Tracy Type of Casing <br /> M Public f_1 Other 1=1 Delta Specifications, J <br /> Depth of Grout Seal <br /> I 1 Irrigation _q Type of Grout <br /> *--*"Type <br /> / pprox. Depth I I astpm dace Seal Installed byl _F <br /> Repair Work Done *- Type of Pump �� t!l.I p <br /> 5tIate Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material (top 50') r i <br /> J� Depth iFiller Material (Below 50') <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 Arl`AIR/ADDITION I 1 DESTRUCTION;( 1%(No septic system permittIse-e, <br /> F <br /> Installation will serve:_ Residence t available within 200 feet.) , <br /> Ali — Commercial Other f <br /> Number of living units: Number of bedrooms �'��. N 1 <br /> Character of sail to a depth of 3 feetI� <br /> SEPTIC TAWK� " " Water table depthk <br /> ❑�..TYPe/Mfg....;.�..._..�� -_........_ -.. ._. _-.- w --,..�..�,..-.-.���,.� <br /> PKG. TREATMENT PLT. ❑ Capacity Nii�Co-m`partmerits <br /> A Method of Disposal <br /> Distance to nearest„ We)I. <br /> ss Foundation Property Line <br /> LEACHING LINE ❑ No. & Lengthiof lines' <br /> FILTER BED ! f -r` - _ q Total length/size <br /> EJ Distance to nearest: Well +• Foundation <br /> 1.t t Property Line <br /> SEEPAGE(PITS I I Depth <br /> Size f Number <br /> SUMPS l0 C1` Distance to nearest aWell t <br /> DISPOSAL PONDS undation Property'Line <br /> ID <br /> ��f,'+f::! � � <br /> hereby certify that t have prepared this application and that the work will <br /> rules and regulations of the San Joaquin Local Health District. be>done in accordance.with San Joaquin county ordinances, state laws, and r <br /> I Home owns is in such <br /> age 's signature ce tifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ person in such ma ner as to become subject to workman's compehsation laws of California." Contractor's hiring or sub-contracting signature <br /> certifi the following: '9 cert' that in the pertorman of the work for which this permit is issued,1 shall employ <br /> tion ws of California." - p p y persons subject to workman's compensa- <br /> Th appli ant mus f all req s C ' ple drawing on re 'r e, <br /> Signe <br /> Title_ Date: <br /> a FOR DEPARTMENT USE ONLY <br /> Application Accepted by 'Q <br /> Date ® C� Area <br /> Pit or Grot Inspection by D2EG <br /> Final Inspection by Date <br /> } Additional)Comments: <br /> © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835.6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT�NO. <br /> +.EH 14-26(REV.1 iKJI15l � <br />