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s. .. <br /> -APPLICATION-FOR PERMIT- - - �— �--c'--- - ---- - - " = <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED <br /> (Complete in Triplicate)"I <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. ;b a <br /> Job Address City Lot Siz6_/ l PM <br /> RANDY Aev4POVICJi <br /> Owner's-Name Address Yy rtil4Ll 'S/1! Phone J� <br /> Contractor AddresM!,Q License NV422��.Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSLLATION ❑ . .J. SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKrSEINER LINES DISPOSAL FLD. PROP. LINE i <br />;i. FOUNDATION` � AGRICULTURE WELL OTHER'WELL PITS/SUMPS r ,w <br /> rFiNTENDED USE TYPE OF WELL *PROBLEMAREA CONSTRUCTION SPECIFICATIONS a- <br /> ❑,Industrial ❑ Oen Bottom <br /> t p GV❑.Manteca Dia:of(Nell Excavation ;-- Dia. of Well Casing." <br /> + ❑ Domestic/Private I] Gravel Pack ElTracyType of Casing , Specifications .y. <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �4pprox. Depth ❑Eastern Surface Seal Installe4dlyr <br /> Repair Work Done ❑ Type of Pump 1 H.P. t--Y-14—AT''---'-State Work Done � 'I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') f I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION% REPAIR/ADDITION ❑ DESTRUCTION ❑ (No'septic system permitted if public sewer is <br /> 11 .. - 1 available within 200 feet.) lu <br /> Installation will serve: Residence— Commercial_ OtFierILL <br /> t�ME; A <br /> i <br /> Number of living units: Number of bedrooms !j A,, <br /> Character of soil to a depth of 3 feet: <br /> Water table depth 7� <br /> SEPTIC TANK; Type/Mfg Capacity} p tyNo. Compartments 2 lidd <br /> PKG. TREATMENT PLT.❑ "` Method of Disposal 1 <br /> {� Distance to nearest: Well 1:50 Foundation ,:Property Line : <br /> LEACHING LINE No.'&Length of lines <br /> ';1 Total length/size if a <br /> FILTER BED ❑ Distance to nearest: Well `'Foundation. Property Line . <br /> SEEPAGE PITS Depth Size:' Number <br /> SUMPS �/E] Distance to nearest: Well.. ', �`' 2 ` 4 <br /> '-1 s0 Foundation� Property Line � � ,.�I <br /> DISPOSAL PONDS ,❑ <br /> I he 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 or licensed agent's signature certifies the following: "I certify thatlin-the performance of the work for which this permit is i d;I shall not i <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:-1 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 /> The applicant must call for all require ns tions. Comple drawing on reverse side. <br /> � <br /> Signed Title:. "'` _. Date: <br /> } <br /> FOR DEPARTMENT USE ONLY <br /> Application ccepted bAby <br /> Date Area _ <br /> Pit or Grout Inspection ate Fi IInspectio byDate <br /> Additional Comments: T�V21 ❑ Manteca 823-7104 ❑ Tracy835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> 1 r / 73 <br /> 44 t, INFO . AMOUNT DUE _ tAMDUNT REMITTED CASH -RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV. ` p .. �q <br /> EFF 14-26 ��� { j S <br />