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' t APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address z City Lot Size ply <br /> Owner's Name ti C . Address . I Z Z/ L� &gg r; `����" t' 'ho ev.,irl�j <br /> �'t 77a <br /> Contractor rte ii!J N fr �Qs�S Address ru'-" K f l��,��a trill .�QLicense No. p <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER;4 MdAJt'1' &W�- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r. <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Sc; t/C Specifications <br /> ❑ Public Other .V� ❑ Delta Depth of Grout Seal Type of Grout Ca,'Z�t1i <br /> ❑ Irrigation __ Approx. Depth Surface Seal Installed by <br /> EI Work Done Type of Pump H.P. State W r Done <br /> ir <br /> Well Destruction ❑ Well Diameter __ _ Sealing Material (top 50') 7"116 CIV Aw <br /> Depth Filler Material (Below 50') AVL <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is <br /> available within 200 feet.) 0 <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> m <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of lines Total lengthtsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation- _ Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ❑ Distance to nearest j Number <br /> DISPOSAL PONDS0���9t10� <br /> I hereby certify that I have "- <br /> rules and regulations p�$per�this application and <br /> Home 9 of the San Joaquin Local that lhe'work will be d <br /> OWner or licensed agent's signature one in accordance with San Joe <br /> employ an Health District. <br /> Y Person in such certifies the followin Joaquin county <br /> certifies the following- manner as to 9 "I certify <br /> ty ordinances, <br /> tion la ,,I ce become subject to workman's that in the Performanc state laws, and <br /> laws of California," that in the performance Pensatlon la a of the work for <br /> Thea of the work for which this of California." which this permit is issued, ! <br /> PPTic t st call for all r Permit is issued,l shall enC,olatractor's hiring shall not <br /> Signed wired ' spec 'ons. Complete drawl P Y persons subject to wokmans sub-contracting signature <br /> on reverse side. compensa- <br /> APplicatiort <br /> Accepted by FOR DEPARTMENT USE ONLY Date: <br /> Pit or Grout Ins <br /> pection - <br /> Additional Com Date l~ <br /> meats: � Area <br /> ❑ Stk 466.6781 Final Inspection by <br /> Applicant- Return all copies to: Eodi 1 <br /> ❑ Manteca 823-7104 Date J, a Environmental Health Permit/Ser <br /> vices 1601 ❑ Tracy '�'�_C) <br /> E. Haxehon Ave., <br /> FEE e• A.O. Boz <br /> INFO AMOUNT DUE $tX, CA�7 <br />'EH r3za rFiEv.pie si �g AMOUNT REMITTED . <br /> EH teas "FVZ ./' <br /> RECEIVED BY <br /> DATE <br /> PER <br /> [ -� m'NO. <br />