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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7.ELTON AVE., STOCKTON, CA <br /> Telephone (209) 468-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District to-a permit to conatn,ct and/or Install the work herein described.This appamtiM+Is <br /> made in compliance with Sen Joaquin County Ordinance No.549 for sewage or No. 1952 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. e7�S� ��Ti�j���( � /�(�� � <br /> Job Address ��S„�r\ CQ City Lot Slee S.�L1�l�..S PM_ <br /> Owner's No" � 1 Address % _ Phone (}��, ` <br /> Contractor k4hi-7 HMI CUAtj Address— � QNLicensa No.43-0-945—Phone I� <br /> TYPE OF WELL/PUMP: NEW WELL 7. WELL REPLACEMENT C DESTRUCTION C <br /> PUMP INSTALLATION 7 SYSTEM REPAIR C. OTHER i:. <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ <br /> C Industrial U Open Bottom Manteca Din. o1 Well Excavation Dia. of Well Casing <br /> C' Domestic/Private D Gravel Pack C Tracy Type of Casing_— SpeeHkations <br /> Public C Other C: Delta Depth of Grout Seal Type of Grout <br /> trrigation ---Approx. Depth Eastern Surface Seal Installed by i <br /> Rerair Work Done Type of Pump ,_ H.P. _ ___ State Work Done <br /> Well Destruction = Well Diameter _ Sealing Materiel Itop 50'1 <br /> Depth Filler Material(Below 501 ',l <br /> TYPE OF SEPTIC WORK: NEW iN`;TALLATION I,.PAIR/ADDITION TRUCTION (No septic system permitted if public sewer is 6 <br /> � � available within 200 feet.) <br /> Installation will serve: Residence AlCommercial_Ather <br /> ____ <br /> Number of living units: —Al— (dumber of rooms <br /> Character of soil to a depth of 3 feet: � `titer tab's depth ^1 <br /> SEPTIC TANK '1. YDIIP/Mfg _ _ _ ,_ Conacity� No. Compartments <br /> PKG TREATMENT PLT. Method of Disposal _ <br /> h1 i <br /> Distance to nearest: Well 1_Q9_+Foundation�5 Property Lino <br /> LEACHING LINE 8 Length of lines — — _ _ Toyl length/sire _ <br /> FILTER BED :- Distance to nearest: Well � foundation _ Property Line�O F) <br /> SEEPAGE PITS 1,Aftth Sire T _ _ Number <br /> SUMPS Distance to nearest: Well .L Foundation!7— property Line f�t <br /> DISPOSAL PONDS <br /> I hereby certify that I hav preper3d this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a <br /> rules and regulations of the San Joaquin Local Health District. <br /> Hot"owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall not <br /> employ any pawn in such manner as to become suhject to workmen's compensation laws of California r:OntrsctOrs hiring or sub-contracting Signature <br /> certNles t Mowing:'I pernty that in the performance of the work for which this permit is issued,'shall employ persons subject to workman's componY- <br /> tion laws of rnis." <br /> The hent est or all uire 'nspec ns. tjZ�drawing on re rse side. _ �^ <br /> Signed Y� — _-- _ Title: — _ Date <br /> FOq DEPARTMENT USE ONLY q <br /> Application Accepted by _ _ _ _ Data <br /> Area <br /> M D <br /> Pit or Grout Inspect by �v _ Finsl Inspection by <br /> Additional Comments <br /> Silk 465-6791 Lodi 399.3621 _ Manteca 823.7104 Tracy 835 6395 <br /> Applicant - Reium all copies to: Environmental Health Permit!Services 1901 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> I NFA _ _— _.�_ — <br /> .:• ary -- --7 L" • CSO ?, t 1 C Jr- ��s f�7 R7�7 <br />