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APPLICATION FOR PERMIT ! <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone.1209) 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 6 yY Ciryro� Teri tic% City ' F's4-4744oA' Lot Size AFWCA PM <br /> ^ t � <br /> Owner's Name Toe-- /3t? Ll e.75 Address b e.97-YOL ne, Phone I <br /> W . <br /> �ODa Q�vF' License No. <br /> _ Contiactor= 1 I A' Ski!' Address cr�f yy��9 Phone_ <br /> TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION ❑ <br /> + r PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES w DISPOSAL FLD. PROP. LINE <br /> " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> I <br /> INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public C1 Other F1 Delta Depth of Grout Seal Type of Graut <br /> ' I Irrigation t _.-Approx. Depth i I Eastern F Surface Seal Installed by _ <br /> Repair Work Done ❑. Type of Pump H.P. f State Work Done <br /> I Well Destruction ❑ Well Diameter Sealing Material (top 50') �+ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION kf REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is p <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: /.. Number of bedrooms X <br /> Character of soil to a depth of 3 feet: _0'44w___ Water table depth <br /> SEPTIC TANK )J Type/Mfg Ie CA.Ar Capacity 12470 No. Compartments <br /> PKG. TREATMENT PLT. O / Method of Disposal <br /> i Distance to nearest: Well f✓d` Foundation 0-1' Line S' <br /> LEACHING LINE ` el No. & Length of lines Total length/size ya'� <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Sizey,,P ly.l ze Number <br /> SUMPS V Distance to nearest: Well `—?Cr'' foundation -l-S Property Line S <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. _ _ _ I <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„1 shall not f <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> -The.applicant musl call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: ­4 <br /> Date: <br /> OR.DEPARTMENT'OSE'ONLY - P <br /> Application Accepted by <br /> Data Area L ._-.- <br /> __ <br /> Pit or Grout Inspection by Date Final Inspection by Oat.LL <br /> 'Additional Comments: <br /> ❑ Stk,466-6781 ❑ Lodi 369-3621 CI Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE a PERM17,NO. <br /> a EH13-21(kEV,1/K5] -7 �jI <br />