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0 10S' <br /> Q APPL'GATION 0FOR PERMIT ;-� <br /> fJQ� ! ) Z 0 ('^� SAN JOAQUIN LOCAL HEALTH DISTRICT 4;!S, 'C1601 E. HAZELTON AVE., STOCKTON, CA L� �y f� <br /> Telephone (209) 466-6781 -i /`-' _ o r - <br /> RIO o�. <br /> �,� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C©Py, <br /> (Complete in Triplicate) <br /> IApp ation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicatiorr <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 Joaq, <br /> Local Health Districts. A <br /> -Job Address r./t�/J/iy �d s4 / City � of Size PM <br /> Owner's Name Address ray (��® 411 Phone <br /> Contractor Address License No. Phone/p <br /> 3 <br /> TYPE OF WELL/PUMP: NEW WELL LI WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> Qd PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PP OP-� ; <br /> FOUNDATION AGRICULTURE WELL OTHPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRU PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications <br /> I'] Public F1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation prox. Depth l I Eastern Surface Seal installed by <br /> Repair Work Done Type of Pump H.P. State Work Done_ <br /> (� <br /> Well De ion ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIR/ADDITION l i DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> \ Installation will serve: Residence_ Commercial_ Other <br /> \V\ Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal-. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total Length/size- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <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, a <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 r <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatt <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 compen! <br /> tion laws of California." <br /> The�applican t cal! for a!I required ins ciions.�mplete drawing on reverse side.ignTitle: Date: !� i �f O / <br /> FOR.DEPARTMENT USE ONLY <br /> Application Accepted by / ' �-r2-ai(j-�?-. Date 6 AY V Area 0.3 <br /> Pit or Grout InspectiDate Final Inspection by.k �(✓� �- Data441 <br /> Additional Comments <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca - 104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEERMIT'N�Oj. <br /> a EH 13-241REV.t�Hs1 ,�U 3S•t,'�� j ��—zy—�7 �/^2 74// <br /> Di t4-20 <br />