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n F <br /> � n <br /> APPLICATION FOA PERMIT <br /> SAN;JpA0U1N'LOCAL HEALTH DISTRICT • <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICOmplete in Triplicate) <br /> t and/or and the polls"d Regulations of the Sen Joaquin <br /> Application is hereby made SatohSJoaquin Joaquin <br /> odnN Ordinance No.D54S for sewage ora <br /> N0-1982 for well/pumps ndtall the worherein described.This eppl'ication s <br /> made in comp' SPAC c�C� <br /> Local Health District. +`-Y� <br /> City <br /> ,_ Lot Size._----- PM <br /> Job Address - <br /> t�•� tw1 hl -� Phone <br /> Address <br /> ownoei .Nsme <br /> Phone <br /> i License No.4! DESTRUCTION 11Contractor's Name. NEW WELL ❑ WELL REPLACEMENT ❑TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLD• PROP. LINE <br /> SEWER LINES OTHER WEII PITS/SUMPS <br /> k DISTANCE TO NEAREST! SEPTIC TANK AGRICULTURE WELL ' <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Calling I } <br /> ❑ Open Bottom ❑Manteca Die. of Well Excavation Specifications LLL <br /> ❑ Industrial Type of Casi - <br /> ❑Domestic/Private Cl Gravel Pack ❑ Tracy YP Type of Grout <br /> ❑ Public <br /> ❑Odwr ❑Delta --.i Depth of Grout Seal.—... r^} <br /> Cl Irrigation �PProx, Depth ❑ Eastern Surface Se ,lnstelled by <br /> j e Steta'Vfoik Done'y <br /> 1{ Repair Work Dona ❑ Type of Pump pealing Materiel ltap 60'1 <br /> Well Destruction ❑ Well Diameter' + r <br /> Depth Filler Material (Below 571 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR7ADDI I ION O"DES'fADCTION❑ available with!! 20D fe t..) d public sewer 15 <br /> .) Installation will serve: Ree(kinca -_-CpPlfnercial _# Other <br /> Number of b4dPooms --^-*-'-�'�" <br /> Number of living units: 1- 4 .� Water table depth -� <br /> Character of soil to a depth of 3 feet: r-^ ' 17[Y> (.,AL No. Compartments <br /> rType/Mf X t.MV&IVy Cepeefty 7b <br /> � SEPTIC TANK ,�f g ��"�j � Method of Diepoael <br /> PKG. TREATMENT PLT.❑ L...T:.,.......T..a.—•- _* /=' <br /> property' <br /> f <br /> Distance to neargst: Well=- Foundation— Line <br /> —lct!— •II <br /> i <br /> Total length/siz <br /> LEACHING LINE ❑ No.&Length of lines Property Line <br /> FILTER BED �( Distance to neaestt : Wall Foundation `•,; C <br /> I SEEPAGE PITS Depth Sze <br /> Number <br /> 0 -. <br /> SUMPS Distance to near�sC Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done In accordance With Sen Joaquin county ardlances,state laws,and <br /> t rules and feguletions of the Sen Joaquin Lova)Health District. <br /> 1 Home owner w licensed agent's signature cartes the fallowing:"I certify that in the Pei of the work for Which this Permit o issued,I shell not <br /> empty any parson In such manner as to become subject to workman's compensation laws of CO Contractors hiring or subconvactingosmperN� <br /> E employ <br /> the following:"I rsrtity that in the per(brmence of the work for which this permit is Issued,I shall employ persons subject to workman!k mpe <br /> tion ism of California." <br /> The applica must call for all required Inspections. Complete drawing on reverse side. <br /> r <br /> .�- Mfif.!? Date: <br /> Signed Tide: <br /> 4 <br /> la <br /> 1 FO PARTMENT USE ONLY <br /> Date <br /> ce - Area cx <br /> Application Acpted Date9 <br /> t , <br /> Ph or Grout lapection Date Final Inspeofion h <br /> t <br /> Additional Comments: <br /> ❑ Stk 486-8/91 ❑ �l33621 O Manteca 1373-7104 ❑Tracy 935•t�,85 <br /> t Applicant-Return all copies fol Envimmont i al Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 <br /> z fI1314 J_K/ • <br /> FEE K RECEIVED eY DATE PERMIT100. <br /> INFO AMSOUNT DUE AMOUNT REMITTED CASH <br /> 1 t'GC X1.5 . ca e 1ff.�o <br /> a FH 13-211(REV 10/x31 <br /> e31 t423 � <br />