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APPLICATION,FOR,PERMIT <br /> SAN JOAQUIN10CALMEALTH DISTRICT <br /> 1601 E. HAZELTON.-AVE., STOCK-TON, CA <br /> A e-2 <br /> Telephone QW) 466-6781 <br /> PERMIT EXPIRES­1'.,YEA1R FROMDATE <br /> 00f-?A0rJ!;o'L'.- "Vic <br /> �JCoMplete�ip.-Tripil,ate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d6kribed'.This application is <br /> made in compliance with:$an,Joaquin-County-Ordinance,No.-,549.for-.sewage or No.1862-for well/pump and the-Rules:end Regulations of the San-Joaquin <br /> Local Health <br /> 7i <br /> sh= D, <br /> C 4'6�C%.Lo�t'Size <br /> Jo Address� Pfi VI :1 7 17 -7-77 .,Z P,M. <br /> 7' <br /> Owner's Name ddress Phone <br /> Al <br /> Contractor's Name License Na. Phone.,f iX <br /> TYPE OF WELL/PUMP: NEW WELL. ID WELL:REPLACEMENT`0 `;DESTRUCTION 0 <br /> PUMP INSTALLATION D SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' N! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL—`PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,.,SPECIFICATIONS <br /> LJ Industrial 0 Open Bottom E3 Manteca Dia.'of W411 Excavation"lit Dia. of Well Casing <br /> El Domestid/Private 0 Gravel Pack ID Tracy Type of Casing Specifications <br /> 0 Public ri Other 0 Delta Depth of Grout Gail Tyj13 of Grout <br /> 7 Irrigation -"- .. .1 <br /> ---Approx. Depth 71 Eastern Surface Seal Installed by <br /> Repair Work Done F-1 Type of Pump H.P. S_ta�ta Work Doni <br /> Well Destruction Ll Well Diameter Sealing Material 40p 50,I. <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION El 'DESTRUCTION El (No septic system,$'permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 1____C <br /> ornmercial Other <br /> Number of living units: Number of bedrooms_-:3 <br /> Character of soil to a depth of 3 feet- <br /> Water table,d6pth <br /> ,SEPTIC TANK El 'Typ6/.Mf.g Calplacit.V!, 4 'No. Compartments <br /> PKG. TREATMENT.PLT. 1-1 Method of Disposal <br /> Distance to nearest.- .Well Foundation .,Property Line /ttle] <br /> No. & Length of lines <br /> LEACHING LINE _ �otal length/size— <br /> FILTER BED L1 Distance to nearest: :Well Z[9,10 -Foundation _-_-Property Line /4,9 <br /> SEEPAGE PITS Depth Size Number <br /> 70 <br /> .SUMPS 0, Distance to nearest:— -Vell: Foundation /C :1`, Property Line <br /> ,DISPOSAL PONDS 1-3 <br /> I hereby certify that I have prepared this;appiicati�n and that the lwork 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 /> Norrie 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 followilqq:"I 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 rallrequiR6dfnApections. Comp)9t5 drawing on rev side. <br /> Signed Title: Date: <br /> FUR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Data Area <br /> Pit or Grout kspecilon by Date CJ Final In'spection b, i/ '� baald�f9 <br /> Additional Commeri,ts: <br /> D :Tracy 835-6385 Stk -466-6781.-- E] LOCH..360-36211 171-Manteca 823-7104 - 171 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.; CA 95201 <br /> FEE -,—AMOUNT DUE';- f AMOUNT REMITTED "CK REt.EIVEW BY DATE PERMIT';NO,E <br /> 0 <br /> INF CASH <br /> 4 N T ­ <br /> EH 1324(REV,tOf831 1- <br /> __EH 14-28 i <br />