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APPLICATION FOR PERMIT J <br /> SAN JOAGUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA N'Evi <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r Application is hereby made to the San Joaquin Local Health District for a <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 /> r permit to construct and/or install the work herein described. This application is <br /> Local Health District. <br /> Job Address 134.00?. 011er rd <br /> city�'tODI Lot size <br /> PM <br /> Owner's Name BA�D �.{lfr Address <br /> k <br /> Contractor �r-�+ Phone <br /> Kc��'N GRnSB, Addres _ <br />` TYPE OF WNEW ELL/PUMP: License Nq�rj'� ari Phone <br /> W [ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATIO DESTRUCTION ❑ <br /> 'SYSTEM REPAIR El> � ., '� OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC-TANK ^"-----�^-�--- Lf _4m- <br /> SEWER"LINES'—= ��,__DISPOSAL-FL-D. <br /> FOUNDATION � AGRICULTURE WELL -�PAOP�L-INEY�00 � <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [� Industria! ❑ Open Bottom '� -���—� <br /> I❑>Manteca Dia. of Well Excavation <br /> Domestic/Private 4tftravel Pack f - Dia. of Well Casing <br /> ❑-Traaccy Type of Casing <br /> i'1 Public i�f Other Specifications <br /> i I Irrigation nsDelta Depth of Grout Seal '-t <br /> 5a_-.Approx. Depth I 1 Easter - Type of Grout r"'1Ttp� <br /> Repair Work Done L7 Type of Pum Surface Seal Installe y n n <br /> Pump H^P' _ -..State Work Done <br /> Wel! Destruction ❑ Wel! Diameter � <br /> Depth Sealing Material {top 50') <br /> p Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION 1 1 DESTRUCTION I 1 (No septic system permitted if Public.,' is <br /> Installation will serve: Residence f available within 200 feet) <br /> Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: LWj <br /> kw <br /> SEPTIC TANK ❑ Type/Mfg ` ' Water table depth <br /> Capacity. _ �_ <br /> PKG. TREATMENT PLT. ❑ _ No. Compartments <br /> Distance to nearest: Well °Found___n _ Method of Disposal <br /> Foundation Property Line <br /> � I <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED r Total length/size <br /> ❑ Distance to nearest: Wel! rr` <br /> Foundation Property Line <br /> SEEPAGE PITS i1 Depth <br /> Size <br /> SUMPS Number 4 <br /> L7 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 Joaquin county ordinances,'state laws, and <br /> rules and regulations of the San Joaquin Local Health DI�trict. <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as to become subject to workman's ciompensation lfy that in the aws Of Califorrnia."Contractonce of the work for r's or sub-contracting ls gnanot <br /> turre f <br /> certifies the fallowing; "I certif that in the Performance of the work for which this Permit is issued, I shall employ tion laws of California." y <br /> r^ _ P y persons su6jact to workman's compensa <br />+r 1J The applicant must N f all r wired ���lrawing on reverse side. <br /> Signed X -i. j <br /> Title: O` IEIR date: 9-10-39 f <br /> r <br /> F DEPARTMENT USE ONLY f <br /> Application Accepted by Q� q <br /> Area <br /> ` G 1 <br /> Pit or1t Inspection by Date /. r <br /> Final Inspection by <br /> Additional Comments: Date t <br /> . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7101Tracy UG d <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelt n 3Ave., P.O. Box 2009 Stk., CA 95201 <br /> EFEO <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVEp BYCASH DATE PERMIT'NO. <br /> 51 ��EH 34-2aEH 1324{pEV.t i nO , <br /> e V // —1�qr 7'l " <br />