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APPLICATION FOR PERMIT <br />Y_Gll t, j_5 __9 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON ON AVE., STOCKTON, CA Ie <br />Telephone (209) 466-8781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby de to the San ,Joaquin Local Health District for a permit to construct and/or instal'= the work herein described. This application ;s <br />made in compliance with San Joaquin County Ordinance No. 549 for sewage of No. 1862 lot wefi]pump and the Elutes and Regulations of the San Joaquin <br />Local Heelth District. <br />Job Address Vl%._? 1_a! . ' City Lot Size _ .y.�... PM <br />✓ i r 'j i TJ . �'� � }zrZ Phone C1' <br />)Ownor's Name _ j _. Addressc,�„_. �_r�'t/ e <br />Contractor 1�{Vi.' 71VNfGL�Address _ _��Y "A "cense Nb.. ...,... Phon6ZZ , <br />TYPE OF WELL/PUMP: NEW WELL 10 WELL REPLACEMENT f7 DESTRUCTION�0 <br />_. PUMP INSTALLATION W SYSTEM REPAIR 0 <br />DISTANCE TO NEAREST: SEPTIC TANK ._....._�_.. SEWER LINES Dl FLD, PROP. LlN£. <br />FOUNDATION , AGRICULTURE WELL OTHER WELL...... PITSISUMPS <br />INTENDED USE <br />17 Industrial <br />Cl Domestic] Private <br />0 Public <br />l; irrigation <br />Repair Work Done <br />Welt Destruction <br />TYPE OF WELL <br />Open Bottom <br />F! Gravel Pack <br />(j Other <br />71 Type . <br />Well <br />Depth <br />WORK. NEW INSTALLATION <br />PROBLEM ARE ' NSTRUCTION SPECIFICATIONS <br />Ma Dia. of Well Excavation <br />racy Type of Casing__ <br />0 Dema Depth of Grout Seal <br />0 Eastern Surface Seal Installed by _....... <br />..... Seiafir4 Material (top 501 <br />Filler Material (Below 501 <br />REPAIR/ADDITION t” I DEST) <br />Installation will serve: Residence.— Commercial w___._ other ...... ..___ <br />Number of )'suing units: <br />— Number of bedrooms _ <br />Character of sort to a depth of 3 feet: <br />SEPTIC TANK e <br />Type/Mfg .. _. Capacity <br />PKG. TREATMENT PLT, 11 <br />i � <br />Distance to nearest: well Foundation __.. <br />LEACHING LINE i_) <br />No. ffi Length of lines <br />FILTER SED n <br />Distance to nearest: Weil _.. Foundation <br />Dia. of Weil Casing <br />Specifications <br />Type of Grout <br />(No septic system permitted if public sewer is <br />available within 200 feet.) <br />Water table depth <br />No. Compartments <br />Method of Disposal <br />Property Line ._.... — <br />Total length/size— <br />__..._._,. Property Line <br />SEEPAGE PiTS 0 Depth _ _ Size _._.. Number <br />SUMPS 1-1 Distance to nearest: Well w _ Foundation ------ — Property Line _ — �_ � • <br />DISPOSAL PONDS Q I - ; <br />t hereby certify that i have prepared this application and that the work will be dote in accordance with San Joaquin county ordimntes, state I3ws, and <br />rules and regulations of the San Joaquin Local Health District. <br />Hcrrue owner or licensed agent's signature certifies the Blowing: "I certify that in the performance of the work for.*hich this permit is issued, I shall not <br />employ any person in such manner as to become subject w workman's compensation laws of Cahfomia."- Contractor's hiring dr sub -contracting signature <br />certifies the following. ''l certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman s comperrsa <br />tion laws of Califorrua." <br />The applicant must call for all required i cttons. Complete drawing on romM side. <br />Signed X__/5 41e_ Title: W.. _._ Date. <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by -� r �y� . _..., v� .. _. Date _ t... ` t !� ! L .. Area 21 <br />Pit or Grout Inspection by _ _ Date final Inspection by� _ Date"✓'4ir�� <br />T_ <br />Additional Comments:,,- <br />C1 Stk 466-6Al a Lodi 365-3621 , L1 Manteca 823-7104 0 Tracy 835.838b Ail <br />Applicant - Return all copies to: Environtr ental Health Permit/Servirvs 1601 E, Hazelton Ave„ P.O. Box 2409, Stk., CA 95241 i� <br />tFEE AMOUNT DUE <br />AMOUNT REMITTED <br />SFi RECEIVED By <br />DATE <br />�'PEEAW7"40. <br />