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s a i <br /> ` APPLICATION FOR PERMIT <br /> is <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I, Telephone (209}.466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE 'I ED' <br /> r °`UT✓1' <br /> SSU <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or irYstall t� work herein described. TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t e Rrfles and Regulations of the San Joaquin <br /> Local Health District. '' t <br /> Job Address 10%DCity �/� a Lot Size PM <br /> Owner's Name t l(A t-al_ && Address / I I NYA Oat &4L j� .Phone �02 39- 96 <br /> Contractor AftAU Address ILZ�,M8U.License No. 02904F/3 Phone 6-715--ja <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION D i SYSTEM REPAIR ❑ r OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK IOC �- SEV EWLINES,.._—..­ -DISPOSAL FLD.f00�fi PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS h <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 60NSTRIJC-flON SPECIFICATIONS <br /> ❑ Industrial D Open Bottom ❑ Manteca i "Dia. of Wel ~Excavation 10Dia. of Well Casing <br /> XDomestic/Private X Gravel Pack Tracy Type of Casing r Specifications <br /> f7 Public Ll Other 1-1Delta_ . `� . Depth of-Grout Se "Type of G <br /> ❑ Irrigation j --Approx. Depth ❑ Eastern Surface Seal a[E, ;� �611-ZO-4 <br /> Repair Work Done ❑ Type of Pump H-P, State Work Done <br /> Well Destruction ❑ Well Diameter- Sealing Material (top 501 '. <br /> Depth Filler Material (Below 501 J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D (No septic system permitted if public sewer is <br /> available <br /> within-200 feet:)-.- <br /> y <br /> Installation will serve: Residence! Commercial— Other <br /> I r..;----Number-of-living units: -Number of bedrc`oms'�—=-----'-77T <br /> Character of soil to a depth of 3 feet:'1 ' ' w rt Water table depth �J <br /> SEPTIC TANK LlType/Mfg l Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ; `r Method of Disposal <br /> + Distance to nearest: Well Y <br /> Foundation Property-Line <br /> LEACHING LINE ❑ No. & Le gth of lines �"�""�" `' "� Total length/size _ <br /> i <br /> FILTER BED i❑ Distance to nearest: Well l Foundation--- - ' - Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �4 - <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 Joaquin1ocal Health District. 71. <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 pentons subject to workman's compensa- - <br /> tion laws of California." <br /> The applicant st call for�all reqire pections. C mplete drawing o r r de. 1 <br /> Mau— <br /> Signed Title: Date: <br /> , # <br /> FOR DEPARTMENTE ONLY <br /> Application Accepted by Date Area Q <br /> Pit or Grout Inspection byate j Z` Final-Inspection by Date <br /> Additional Comments: ! �� r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1 D Manteca 823-7104 [ ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box'2009,•S&, CA 95201 <br /> FEE INFO AMOUNT DUE ' AMOUNT REMITTED 0 SH RECEIVED BY DATE PERMIT'NO. <br /> +EH 13-24 EH 14-26fREV.3/a 51 <br /> Q <br /> �S5 <br />