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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 486-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.TNa application is <br /> made in compliance with San Joaquin 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. <br /> Job Address -' 7;2 �� STYer+CT City_5 C Lot Size -3/'y�y'�"� PM <br /> Owner's Name tr3A 21 V .44 4 ±,jeAddress r '•: Phone 'Z vx& <br /> Convector's Name ti'T I 90 fow License No. Y�y' ��� Phone .T J7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INST.OA�LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST.-SEPTIC-TANK _ .• SEWER LINES DISPOSAL FLO, PROP. LINE <br /> 1 FOUNDATION t AGRICULTURE WELL _________ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well CasiN <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> C Public ❑ Other O Detta Depth of Grout Seal Type of Grout �} <br /> ❑ Irrigation !--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done G Type of Pump I H.P. State Work Done <br /> Well Destruction C Well Diameter I Sealing Material (top SY) ►1 <br /> Depth I Filler Material{Below 50') _ 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑t�REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> J ? available within 200 feet.) <br /> tR�n4 <br /> installation will serve: Residence Z— Commercial_­-�Jr r <br /> t . -.t 1 <br /> Nurci�er of living._un. ris:- Number of bedrooms <br /> Character of soil to a depth of 3 feet: .'A it �LdWater table depth <br /> SEPTIC TANK 2� Type/Mfg CdAsT Capacity e?JW0 No. Compartments 3 <br /> PKG. TREATMENT PLT.❑ i Method of Disposal <br /> f Distance to nearest: l Well Foundation /O% Property Line 0 <br /> LEACHING LINE ❑i o. & Length of(ir, Total length/size <br /> FILTER BED p` Di nCff to-nearegt^" Well Foundation �f� Property Line r' <br /> SEEPAGE PITS ❑ Depth _ ; ` Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line L� <br /> DISPOSAL PONDS l ❑11`� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances tate laws,and <br /> rules and regulations of the San Joaquin Lo I-;Health District. <br /> Home owner or licensed agents signature cues the following: 1 certify '' <br /> m to an '� rtify that in the performa�hce of the work for which this permit is issued, I shall not <br /> e <br /> y y person in such manner as to b4come subject to workman's compensation laws of Calfornia."Contractor's hiring or sub-contracting signature <br /> certifieg the following:"I certify that in the perfoananse.of the work for which this permit is issued, I shall employ persons subject to workman's compenaa- <br /> tiorn laws of California." ii <br /> The applicant mu call for a0 required Inspect}ons. Complete drawing on reverse side, <br /> Signed Title: fr <br /> Date: <br /> r FO EPARTMENT USE ONLY <br /> Application Accepted [� <br /> P by ?!j" Data ! ` F � Area <br /> i ' ' " <br /> Pit or,Grout Inspection by � -Data•--•-•�, Final Inspection by a <br /> � i z7"f �� �.� <br /> C '�__ Data <br /> Additional Comments: s — <br /> ❑ Stk 466-Mi ❑ Lodi 369-3621 ❑ Manteca 823.7104 .__ G Tracy 835-6385 <br /> Applic <br /> ant- Return all copies tp:Environmental Health Permit/Services 1601 E. Hazatton Ave., P.O. Box 2005, S*., CA 96201 <br /> I � - <br /> FEE MOUNT DUE AMOuwr REMITTED CAH RECEIVED BY DATE PERMWN0. <br /> INFO <br /> H 13.24[REV.tora3r 7 op lq <br /> Eg5 85-35� <br /> ri 14.26 , <br />