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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA {�,� <br /> Telephone (209) 466-6781 'vl� <br /> 1 <br /> � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 <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 descnbe�d Thi$a <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 Sar Joaquin' <br /> Local Health District. pp Icarian is <br /> Job Address �!--i�� 72-0 0-k ror-,l G(e_ �`' __ +' , <br /> City O t'1`ot Size PM <br /> Owner's Name�C?.`t�� Crt ddress Q <br /> Phone <br /> f Contractor _ Address <br /> TYPE OF WELL/PUMP: Dicense No, Phone <br /> NEW WELL ❑ WELL'REPLACEME IT ❑ ''DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR-13 �. <br />� DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEINER LINES DISPOSAL FLD. PROP <br /> FOUNDATION AGRICULTURE.WELL+- - OTHER,WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION S PITS/SUMPS _ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ATIONS <br /> Dia. of xcavation `;Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _ ' <br /> ❑ Public ype of Casing <br /> ❑ Other n Specifications: ' <br /> a Depth of Grout Seal ' Type-of,Grout <br /> I I Irrigation Appro l I Eastern <br /> Surface Seal.Installed by <br /> Repair Work Done ❑ of Pump H P <br /> Well a''on <br /> State Work Done <br /> ❑ Well piameter Sealing Material (top 50') <br /> Depth - .acFiller Material`IBelow'50'1 5. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I D1 10 ESTRUCTION V <br /> (No septic system permitted if public sewer is <br /> Installation will serve: Residence k Commercial— Other available within 200 feet.I <br /> _ -t - <br /> Number of living units: 2 Number of bedrooms <br /> Character of sail to a depth of 3 feet <br /> SEPTIC TANK ❑ Type/Mfg Water table depth y <br /> .t Capacity—PKG. TREATMENT PLT. ❑ �- No. Compartments <br /> Method of Disposal ( <br /> Distance to nearest: Well Foundation , j <br /> Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/sire Yy <br /> ❑ Distance-tri nearest Well Foundation <br /> t. Property Line <br /> d <br /> SEEPAGE PITS I I Depth + <br /> Size Number - <br /> SUMPS 0 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Ji1 <br /> rules and regulations of the San Joaquin Local Health District. oaqun.count Y ordin ances, state laws, and <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 comp ... <br /> tion laws of California." - <br /> t ust calf for a i required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: d W 7\-C r— <br /> Date; <br /> MENT USE ONLY <br /> Application Accepted by1�r—�' , <br /> Date_ f .Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> Date <br /> ❑ Stk 466-6781 ❑ Lod; 369-3621 ❑ Manteca 823-7104 <br /> 0 Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO H RECEIVED i DATE <br /> PERMIT'NO. <br /> + EH RE7I.-241 �i <br /> 14 0 <br /> EH 14-2fl ^�� a <br />