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E <br /> r LSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlar install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or NA.1462 for wail/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> C� G <br /> Job Address �� 1 ✓ � � Cityx 4 Lot Size PM <br /> n� <br /> Owner's Name 1. EC7 Kr Al-4 A-S Addrm 1( 7-!Z 1 i'� C�C %OeY& Phone ^ <br /> Contractor Address 5;r4_r/+`^--- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU TION ❑ <br /> PUMP INSTALLATION 0 SYSTEM-REPAIR IJ OTHER C1DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES SAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE T <br /> YPEOBLEM ARE ONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Dia.of Wail Excavation Dia. of Welt Casing <br /> ❑ Domestic/Prnrate ❑ Tracy Type of Casing Specifrwtions <br /> 1'1 Public ❑ fl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation I 1 Eastern rface Seal Installed by _ <br /> i Repair Work Done 13 TyH.P. State Work Done <br /> I <br /> i Well Destruction ❑ Well Diameter Sealing Material ( p 501) <br /> Depth Filler Material(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION t I DESTRUCTION 1 ) INo septic system permitted it public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence L Commercial� Other <br /> Number of living units: I. Number of bedrooms Z, <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK T /Mf jr r <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 I Method of Disposal <br /> Distance to nearest: Well 6 Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines U Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall foundation Property Line <br /> r <br /> SEEPAGE PITS 1—'Depth Size 3 Number <br /> i SUMPS L7 Distance to nearest. Well Foundation Property Line <br /> 61 <br /> DISPOSAL PQNDS',. 0 T <br /> I hereby cenify that I`have.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and <br /> rules and regulations afihe San Joaquin Local Health DRarict. <br /> Home owner or licensed agiht's i:ignature 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 mariner as to become subject to workman's compensation laws of California.•'Contractor's hiring or sub contracting signature ` <br /> certifies the following:"I certify ths6n the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa• G <br /> tion taws of California." <br /> The applicant must colt for all required in dons. Complete drawing on reverse side. g <br /> Signed X Title: A A A -i2r�� ] <br /> C�� /1/<�,.._.__. Date: <br /> FOR R DEPARTMENT USE ONLY <br /> Application Accepted by r Date A A Area Qp <br /> Pit or Grout Inspection by Date f_72_— Fitter Inspection by Date r?4 <br /> Additional Comments: ' <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623.7104 ❑ Tracy _[r� <br /> Applicant-Return aft copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0_ Box 2009, Stk., CA 96201FEE <br /> NFO AMOUNT D'UQE� AMOUNT REMITTED CASH RECEIVED 8V DATE PERMIT-NO. <br /> •.em M24[REV.t/nsl O_ "'� kgz 7-1f-fi 0( <br /> EN WN _:Z0 <br /> J / 7 <br /> - - - - _ - ._.__... .. :V::•:..:_. ... .'!4.•• _. ..�.-.._._ rte. .. � •1• ._ oswr ..r_.. . _ _ <br />