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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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. <br /> Job Address „��� IAS L- 5y City Lot Size 79X 7-C OM <br /> Owner's Name Address Phone gy- 11- <br /> Contractor F[a yD AVd,a D _Address-SAS Al, L![LiA�/ �4 s/� ic�nse No. Phone <br /> f <br /> TYPE OF WELL/PUMP: NEW WELL 1_11 -..ti1,--r-i-WELL_REP_LACEMENT-❑. DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ g� , SYSTEM REPAIR ❑. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK {$ £ SEWER,LINES DISPOSAL FLD. " PROP. LINE <br /> FOUNDATION `r 4 AGRICULTURE-WELL " - -:OTHER-WELL t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL' 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom t D'Manteca Dia. of Well Excavation 'Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ;Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by 4 J <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �pJnn <br /> Well Destruction' ❑ Well Diameter _ I Sealing,Material (top 50') s v V I ! <br /> Depth 1 1 Filler Material ;Below 50') I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JK REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ' ! available within 200 feet.) <br /> Installation will serve: Residence Commercial_Other-- - ----t - <br /> Number of living units: Number of bedrooms-^-1 `L f <br /> Character of soil to a de-pth,of 3 feet: e- _Water table depth <br /> SEPTIC TANK LdthType/Mfg e-e,' L CapacityLLini O No. Compartments `— <br /> PKG. TREATMENT PLT. ❑ ` ' v s . ';,� -""fVlettiod of Disposal <br /> Distance to nearest: Well Foundation —9a—! .P_roperty..Line S <br /> LEACHING LINE No. & Length <br /> FILTER BED ❑ Distance to nearest: Well _ N/Q Foundation JV Property Line <br /> 4 � <br /> SEEPAGE PITS ❑ epth /O Size _.L I X f Y _7 Number <br /> SUMPS Distance to nearest: Well UZA Foundation 76 r Property Line S <br /> DISPOSAL PONDS ❑ <br /> 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 California." <br /> The applicant must call for all required in tions. Complete drawing on reverse side. <br /> Signed Xl=� ' Title: �� __- Date: <br /> FOR DEPARTMENT USE ONLY -, ,! <br /> Application Accepted by Date / �6 Area 0� <br /> Pit or Grout Inspection by Date Final Inspection by ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT"N0. <br /> + EH 3-24 EH 1426[REV.}/Hs) �� �� �­* <br />