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' 7A <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601' E�i�EL i QN'AVE., STaCKTON, CA <br /> Telephone(2b9) 466-6781 <br /> ,, r• 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 /> k <br /> Job Address + 3 city Si PM <br /> Ldrlsery ,-y �A44ele, bye <br /> yo ga./aro ,Bray Ge <br /> Owner's Name Address hone J13 <br /> "4 <br /> Contractor ddress\ ftj L 171''71 'o License No. I 162.3n 3 Phone z <br /> TYPE OF WELL/PUMP: NEOWELL ❑ , *WELL REPLACEMEN ❑ DESTRUCTION <br /> 21„�F 4 \ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR E\ y OTy,ER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL_F-LD, P_ROP...LINE_ <br /> FOUNDATION AGRICULTURE-WELL — OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_$PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well'Excaaation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications (, <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed;by <br /> Repair Work Done ❑ e of Pump H.P. State Work Done <br /> Well Destruction Wf' Well Diameter Sealing Material [top 50') <br /> Depth Z.Z, f Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ .-Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg._-_- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> S <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> r <br /> SEEPAGE PITS ❑ Depth Size ♦Number <br /> r,• <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 ed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not <br /> employ an arson ins h manner as to become su ' ct to workman's compensation laws oftCalifornia."Contractors hiring or sub contracting signature f ` <br /> certifies t following: "t a 'fy that in rfor n of the work for which this permit is issued,I shall employ persons subject to workman's compere♦- `I <br /> tion law of California." <br /> The app icant mu c 'r all r u" s. Co wing r arse;ide � <br /> Signed Title: Date: r+'� <br /> FOR DEPARTMENT USE ONLY <br /> Y`•lamDate ate • � <br /> Application Accepted by � t31 � i 'Area <br /> Pit or Grout Inspection by Date Final Inspection bye_ Date ar <br /> � I <br /> Additional Comments: <br /> I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IEEENFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24 fREV.1/85) 167-7 <br /> EH 14-26 !J O <br />