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/ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 113Q1,,.E: HAZEL i l7N 'AVE., STOCKTON, CA <br /> 1' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate? 1:. a <br /> e work <br /> -This <br /> ication is <br /> Application is hereby made <br /> SanoJoaquin County Ordinance No.District 549 for fosewage or r a permit <br /> No. 1862 for well/dpump install <br /> nd he Rules and'Reguulations of he San Joaquin <br /> made in compliance <br /> Local Health District. o yp <br /> PM <br /> City <br /> Job Address F - O <br />[ Address ? <br /> Al <br /> Owner's me <br /> � a � <br /> 466 <br /> 6 <br /> i � Uctens' Neo: a� Phone <br /> � <br /> ddresstrConffactoi DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL.RE— .-,MENT,❑ <br /> �, _ ` OTHER Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAVR ❑ � '.''4 l <br /> — DISPOSAL FLD. PROP. LINE <br /> I'DISTANCE TO NEARES7i SEPTIC TANK' SEWER LINES _� - . <br /> -)a;FOUNDATION;- <br /> �� A AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> _ <br /> INT f DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTLON SPECVFICATIONS Dia. of Well Casing <br /> ❑ dustrial ❑+ ,0�en Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> estic/Private vel Pack ❑ Tracy Type of Casing <br /> 11rr " ❑ Delta t rDepth of Grout Seal Type of Grout tl <br /> ublic ❑ Other 0 <br /> `►�(y pprox. Dept ❑, stern ace Seal Installed by <br /> ❑ Irrigation r—may" i State Work Done r Q <br /> Repair Work Done Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 3 <br /> Depth Filler Material (Below 50'1 <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailablo e�wth stng 200 feet.) if public sewer is <br /> t I1 A S <br /> installation will serve: Residence 'Commercial Otherj .J <br /> Number of living units: Number of bedrooms ; Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments ( �J <br /> SEPTIC TANK ❑l Type/Mfg k <br /> r Method of Disposal <br /> rPKG. TREATMENT PLT. ❑�. 'r -- ' _ .. .. .'.' �+ - ,;CaL 4. ` i_Property Line— r c� ----r"^_ <br /> iE Distance to nearest:Well Foundation - _ <br /> Total length/size <br /> LEACHING LINE ❑, No. & Length of lines 9Property Line <br /> FILTER BED Q Distance to nearest: Well Foundation _ <br /> Size t Number <br /> SEEPAGE PITS ❑ Depth I Property Line 2- <br /> 4 d Distance to nearest: WellSUM <br /> Foundation - --- <br /> DISPOSAL PONDS ❑ � <br /> I hereby certify that I have.,prepared this application and that the work will be done in accordance with'San Joordinances, state laws, and <br /> aquinticounty <br /> rules and regulati an Joaquin Local Health District. <br /> Home owner icensed agent 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 rson in such lman er as to become subject to workman's compensation laws of California.'4Conuactor's`fii�ing or sub contracting signature <br /> certifies th following: "I cert' at in a perfor nee of ork f ich this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws f Cal'Iforn' ." <br /> The appli ant mus or 11 requ' dra 'ng on r s /Q <br /> Title: ( Date <br /> 6a_ <br /> Signed <br /> * FOR DEPARTMENT USE ONLY <br /> Alaa r, <br /> Date ' A- <br /> Application Accepted b <br /> f=inal Inspection by bats" r f <br /> Pit or Grout Inspection Date ::a`+ty -.-, ' <br /> Additional Comments: ❑ Tracy 8356385 M �/� <br /> ❑ Stk 466 6781. <br /> El 369-3621 D Manteca 823-7104 - - <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik:f CA 9520_�j <br /> w`e r w: <br /> GK RECEIVED BY DATE'_ _! ;= PERMIT�NO.' <br /> nFEEA=:MOUNTDUE AMOUNT REMITTED " CASHEH 13-24 IREV. <br /> EH 14-28 <br />