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APPLICATION FOR PERMIT. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 3 l P, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED � J 'Jl�vc stJt-1 <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 /> i 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. LI /� <br /> Job Address .__. �!T IV �' ���C&/Aity AQWW" Lot Size PM <br /> Owner's Name �� Address <br /> Phone <br /> Sys- <br /> Contractor - Address License No.-M-M6 .. Phone - <br /> TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ �ffl.TEM REPAIR C1 OTHER ❑ <br /> ff <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k "a <br /> f0U ;11p0�1+" t AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE i TYPE OF WEy L� r: eR9BL`EI4AAREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 1 0 Open Bottom' ❑ Manteca' <br /> r� pia. of Well Excavation Dia. of Well Casing <br /> D%Domestic/Private ��� Gravel Pack 0 TracyF,I (��Type of Casing � Specifications <br /> f l Public I�I Other I t f�i Delfa� Depth of Grout SJal Type of Grout <br /> I ] rrigation L--Approx. Depth I 1 Eastern Surface Saal Installed by ` + <br /> Repair Work Done ❑ I`)�/a1 XA4 P. State Work Done _ <br /> 3 Weil Destruction J. <br /> ,V Well Diameter Sealing Material /top 50'1 <br /> r� ,��- /� � <br /> i- Depth C-/D $�sj.g"-'�'F,i �Material (Below 501 -eAEAW <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION (I REPAIR/ADDITION 1,1\ DESTRUCTION I I INo septic system permitted if public sewer�i's` <br /> l available within 200 feet.! , <br /> -�-�"- In tatlatiaW'yt+iffi•serve: Residence_ Commercial'— Other � <br /> �\ ;i Num,a,- bliving units: Number of bedrooms <br /> If , <br /> Character of soil to a dep€h of 3 feet: A Water table depth <br /> ----SEPTIC-TAN K Lis Type/Mfg Capacity � � No. Compartments �`. <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHINGLINE -{^ ❑� No. & Length of lines _ <br /> f � 9 Total length/size <br /> FILTER BED ❑ Distance to nearest: We& `tt-) Foundation i Property Line <br /> SEEPAGE PITS f I I( Depth Size (A"-4k], £• _ Number <br /> I <br /> SUMPS CI' Distance to nearest: WellFoundation I Property Line <br /> DISPOSAL PONDS �' ❑ �` <br /> 1 hereby certify that I-have pr6Pared'this applicR <br /> `atio �and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of thejSan 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 /> r employ any person in such manner as to become subject to workmans compensation iaws 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 /> I <br /> The applicantIrxt� I requir ins ctions. Complete drawing on revs s ide. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLYj:-1:Z- <br /> €€ <br /> Accepted by Date 2y- <br /> Application. Area <br /> i <br /> Pit or Grout Inspection y ! Dat Final Inspection by Date <br /> Additional Comments: I <br /> ❑ Stk 466-67811 ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r t <br /> i <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 49 RECEIVED BY O TEt, PERMIT'ND. <br /> INFO CASH <br /> EH 14-28[REV.1/851 G.JC � -�� fl,— rt�I <br />