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17 <br /> APPLICATION FOR PERMIT <br /> "' L' <br /> SAN JOAQUIN"LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> F Telephone (209) 466--6* <br /> PERMIT EXPIRES­1!YEAWFROM DATE 1&§UED':_- <br /> (CCtmpletb,in.Triplidii!e), <br /> ' . " , .I"',".. .". : ' _ -. -Ji 4Ii-! - . <br /> Application is hereby made to the San�Joaquin Local Health D!strict for a permit to construct and/or insta 11 the work herein.described..This application is <br /> it made in compliance with San J0'aquIn 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. 4 <br /> '4 <br /> Job Address 1006 r_ 61ty PM <br /> 'Owner's Name -2 <br /> -_� Z -7 22 AddresB'4 Phonii' 3 Gju <br /> Contractor actor 4/1,iM' Addless12'0 4 License No)_(e�2 �PhoneUe_zl? <br /> TYPE OF WELL/PUMP- NEW WELL 0 WELL REPLACEMENT El DESTRUCTION E) <br /> PUMP INSTALLATION [I SYSTEM REPAIR El OTHER C <br /> DISTANCE TO NEAREST; SEPTIC TANK [NSEWER LINES — DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL -PROBLEMAREA 7 CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial 0 Open Bottom E3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gr6vel?ack Ll Tracy Type 1 <br /> of Casing <br /> )Specifications <br /> I <br /> 0 Public 0 Other 0 Delta Depth of Grout SealType of Grout <br /> F?Trrigation prox. Depth Eastern Surface Seal Installed by <br /> Repair Work Done [a T� `amLJ Pump H.P. --- State Work Done <br /> Well Destruction El Well:Diameter Sealing Material top 50') <br /> Depth Filler Material /Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 0 DESTRUCTION Ll (No septic syst6rn permitted if public s <br /> 11: _Commercial <br /> . available within 1 200 feet.) ewer is <br /> Other <br /> Installation will serve: Residence- <br /> N <br /> Number f living <br /> um 0 -units:' <br /> atter of soil to a depth of 3 fee <br /> Water table depth <br /> SEPTIC TANK 0Type/Mfg <br /> [I. Capacity— No. Compartments <br /> PKG. TREATMENT PLT. <br /> Method of'Disposal <br /> Distance to nearest: ­ilwell Foundation Property Line <br /> 4k i <br /> LEACHING LINE 13 No & Length of lines Total length/size <br /> 0 Distance to <br /> FILTER BEDi <br /> nearest: Well <br /> Foundation Property Line iv <br /> SEEPAGE PITS 0 Depth _-,S.izeNumbO <br /> SUMPS0 Distance to nearest:* -k�,WeW_ Foundation <br /> I. - _ — Property Line <br /> DISPOSAL PONDS Ll J/7 Ix- <br /> I hereby certify that I have prepa6d this appiication an8'tha't the work will be d6ne in accordance with San Joaquiril county ordinances, state laws, and <br /> rules and regulations of Local <br /> the San�Joaquiri Health District. <br /> Home owner or licensed agent's'bignature certifies the following' "I certify that in the forI which this permit is issued, I shall not <br /> P. performance of the work o <br /> employ any person in such manner as to beco`rn'e�subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the peh4rmance of the work for-which 1his.06rmit is issued,I shall employ subject to work"Man's com'e - I <br /> tion laws of California." mploy persons p nsa_ <br /> The applican St Gall for all uired inspebtions. Complete drawing on reverse side. <br /> If Signed X <br /> Date: 'J_A <br /> FOR DEPARTMENT'U99 ONLY '+ <br /> -Application Accepted by Date Area <br /> Pit or Grout Inspection by ^ Final'iby I nspection b _A — Date <br /> Additional Comments: <br /> 0 Stlk 466 6781 <br /> 17 Lodi :�369-3621 ED Mdnteci' 823-7104 0 Tracy 835--6385 1 <br /> Applicant- Return all copies to; Environmental Health Per'mit/Servicei 1601 E. Ha'zelton Ave., P..0. Box 2009, Stk.,'CA 95201 <br /> FEE AMOUNT DUE_, AMOUNT REMITTED CK4 NO. <br /> INFO CASH RECEIVED By ATE,. PERMIT <br /> EH 324 1 REV.I/a 5) j�y <br /> EH 14-213 <br />