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'J' <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 Triplicate} <br />'. <br />Application is hereby made to the Son Joaquin Local Health District for a permit to construct'and/or4nstall the work herein described. This application is <br />made in compliance with San Joaquin County ordinance No. W for sewage or No. 1862 for well/pu <br />Local Health District. mp and the Rules and Regulations of the San Joaquin <br />Job Address <br />City Siz� <br />Lot PM <br />1 P <br />Owner's Name Address 7-4Phone <br />Contractor. Address <br />se Phon e' <br />TYPE OF WELL/PUMP: <br />NEW, WELL L2 WELL REPLACEMENT C1 <br />DESTRUCTION, 0 <br />PUMP INSTALLATION D SYSTEM REPAIR 7 OTH§R' Li <br />Vit' r <br />DISTANCE 70 NEAREST: SEPTIC TANK ­— SEWER LINES <br />DISPOSAL FLD.—I PROP, U <br />FOUNDATION <br />AGRICULTURE WELL -- OTHER 'WELL -- PITS/SUMPS <br />,INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION -SPECIFICATIONS <br />D Industrial 10 OpenBottomExcavatio . In Dia. of Well Casing <br />. <br />* Domestic/Private 0 Gravel Pack LJ Tracy Type of Casing <br />* Public Cl Other C r ' <br />Specifications <br />13 Irrigation Depth of,Geo <br />Delta ' .Grout Seal ....... : <br />Type of Grout- <br />--Approx. Depth -7,1 Eastern Surface St)nstalled by-._ <br />Re ir Work Done F1 Type of Pump I 11/1� <br />H. State Work Done <br />Well Destruction O Weil Diameter 7 4/ 1 <br />Sealing Materia <br />141MID-501 <br />Filler er Material (Mow <br />ll 50') <br />................. <br />TYPE OF SEPTIC VvUHF,: NEW INSTALLATION 0 REPAIR /ADDlTllONtD DESTRUCTION lUN Ll (No septic system permitted if public sewer is <br />available within 200 feet.) <br />IWstaflation will serve: Residence oinn4ercial <br />i -A�--C . -YOther--­ <br />Number of living units: Number of bedrooms. <br />Character of soil to a depth of 3 feet: P­ <br />SEP'FIC TANK 0 T � /Mfg I ---Water table depth—___ <br />pe dapaCity—/4�—�d— No. Compartments <br />PKG. TREATMENT PLT. El <br />94 7— wju— Method of Disposal <br />Distance toFoundation-1126��— Property Line <br />nearest Well ,.70 <br />t <br />LEACHINPti-INE <br />—O. -No. & Length of lin`e; Tote I'le�ngth /size <br />T Distance to nearest: FiL TIR BED L] '�Vell L," <br />Foundation" rr1Y' Line Pro <br />SEEPAGE PITS Depth FT– Size <br />Distance to n V Number <br />SUMPS <br />nearest: Wei i I Foundation = Property Line <br />DISPOSAL PONDS <br />I he6aby certify that I have prepared this application'ind 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 followino;"'l certify that in the performance of the work for which this�permit, is issued, I shall not <br />an*py any person in such manner as to become subject to workman:s compensation laws of California." Contractors hiring or sub -contracting signature <br />certifies the following: "I certify, that in the performa nc"e -of the woIrk- for which this -permit is issued, I -shall employ p6 Ins subject to'v'vo man's corn <br />,;tion jaws of California.". rsO lu workman's <br />The 6pplicant must call <br />for all rewired !nspections, complete,drawing pq reverse side. <br />Sign6d T ale <br />XL— <br />Date: <br />-—FOR -DEPARTMENT USE -ONLY <br />Application Accepted by Area <br />i . ............. Date A <br />Pit or Grout Inspection by <br />Date Final Inspection by Date <br />Additional Comments: <br />El Stk 466-6781 LI Lodi 369-362 <br />1 1 C3 Manteca 823-7104 D.Tracy 83563 — <br />Applicant - Return all copies to: Environmental Health Permit/Services 7601 E. Hazelton Ave., <br />P.O. Box 200E11" Stk., CA 95201 <br />INFO <br />AMOUNT U N T jDU�E AMOUNT REMITTED CK # - <br />-INFO RECEIVED Z- CASw - MIT'NO. <br />ATE <br />I!Fi 14-26 <br />