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'APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <br /> (Complete in Triplicate) I <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. <br /> Job Address 7_-R_-;2t Lonl.� f �V O �.� City S �c4an Lot Size Ply/ <br /> CA <br /> Owner's Name - t7Gau(,L �,►k C : Address '57-S W • T)'ir� �pf Phone-2-6—S Z'oZ4 <br /> RR B,Frtma f.CA <br /> Contractor Address 3zss I'1115S10CJ3V� License No.a(t')ZJ'4 Phone -u;1-1b <br /> TYPE OF WELL/PUMP: NEW WELL15r, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> El Industrial ❑ Open Bottom . 11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Balm_me, P n Gravel Pack ❑ Tracy Type of Casing SO\ 40 ��/�- Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _^' �� C-� <br /> p Type of Grout rizzi CftP.YIi <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by v @t3 5 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 11 Sealing Material Itop 501 <br /> Depth-.... kie* Filler Material (Below 501 <br /> TYPE OFXWORKNEK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTI N_❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installat : Residence_ Commercial_ Other <br /> Numbes: Number of bedroomsCharactth of 3 feet: Water table depthSEPTIC T ❑ ype/Mfg Capacity No. CompartmentsPKG. TRE . ❑ Method of Disposal <br /> Dista a to nearest: ell Foundation Property Line <br /> LEACHING LINE ❑ No. & Len of lines Total length/size <br /> FILTER BED 1:1 Dist a to no st: Well Foundation Property Line <br /> SEEPAGE PITS Depth _ ize Number <br /> SUMPS O Distance to nearest: We Foundation Property Line <br /> DISPOSAL P S ❑ <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 "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 Callfor to." <br /> The applicant cal al a mspe ons. Com to drawing on reverse side. <br /> Signed Title: 2� e,,! S Data:J_J <br /> i O EP T USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspecti Date ilZ Final Inspection by Date <br /> � <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7 EJ Trac 835-6385 <br /> Applicant- Return all copies to: Environmental Health Per it/Se s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE` INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. <br /> +EH 13-21 PREY.7/e 51 <br /> EH 14-25 <br />