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APPLICATION FOR PERMIT ' <br /> r _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> k Telephone (209) 466-6781 <br /> f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I 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 /> $' <br /> Local Health District. <br /> I • <br />{ Job Address 28708 S. Bird Rd City Tracy Lot Size PM <br /> G Owners Name Leroy Petz Jr. Address 29300 S. Bird Rd/. , Tracy Phone 835-2720 <br /> Contractor____,yenning$% Bros. Address License No._-2908 3 Phone <br /> --545-1185 <br /> k TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEW REPAIR ❑ OTHER ❑ <br /> r• DISTANCE TO NEAREST: SEPTIC TANK 1001+ SEWER LINES DISPOSAL FLD. 100 t F PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELl4 PITS/SUMPS <br /> INTENDED USE - TYPE-OF WELL_— PROBLEM AREA CONSTRUCTION SPECIFICATIONS �_ <br /> D Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> p( Domestic/Private [(Grave) Pack CXTracy Type of Casing _��[�, 5pecifications <br /> I <br /> 1­1 Public ❑ Other f Delta Depth of Grout Seal 10-0! Type of Grout�i1-t4 !i fig_ <br /> I I Irrigation --Approx. Depth { I Eastern Surface Seal Installed by­ driller <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br />' Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> i° <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION i I DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:- Residence r= Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ^" Water table depth a+ <br /> SEPTIC TANK ❑ Type/Mfg Capacity., No. Compartments <br /> PKG. TREATMENT PLT..❑ r, Method of Disposal <br /> Distance to nearest: y,: Well Foundation Property.Line <br /> LEACHING LINE Cl No- & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well FoundationProperty Line <br /> i <br /> SEEPAGE PITS 1'1 Depth Size Number <br /> SUMPS L1 Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDs -- Ellp 4 MENTALHEALTH <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordtnan es,sta <br /> rules and regulations of the San Joaquin Local Health Di$trict. te aws, 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." Contractors 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'i compensa- <br /> tion laws of California." <br /> The applicant must calf for all required inspections. Complete drawing n eve se lido. r _ I <br /> Signed X Title: , <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted bydate — <br /> Area <br /> 4 9�a - <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: _ <br /> C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca r 104 ❑ Tracy 835- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ANIEWs <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> ` INFO RECEIVER 8Y DATE PERMIT'NO. k <br /> +.EH 13-24IREV.1/85) �Q <br /> EH 11-2t1 <br />