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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) 466-6781 <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 and/or Install the work herein descriteed Ths agaseatoon is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt/pump and the Rules and Regulation?of Ito San Joaquin <br /> Lor at Health District. <br /> Job Address _ � �� /L�1. a��i City <br /> Owner's Name Address i___ t Z` Phnnor, _ <br /> Contract f &w ♦ Address ^ License No.i-IJ_9t�_-, <br /> 7YPE_OF WELL/PIJMP, NEW ELL _' WELL REPLAC#MENT iI DESTRUCTION . <br /> PUUIP INSTALLATION G% SYSTEM REPAIR + i OTHER C. <br /> �� rf <br /> DISTANCE T_0 NEAREST: SEPTIC TANK,ter_r � SEWER LINES 0—IC !�, DISPOSAL FID,+¢C♦ _i` PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OKi--- OTHER WELL PITS'SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA- C_ONNSTRUCTION SPECIFICATIONS r tF <br /> I, Industrial (lrvpen Bottom i l Manteca Dia. o}Wall F.cavatronw [`�} w of WNI Casing <br /> ir'Comestic/Private t' Gravel Pack Ttacy Type of Casinel —,1zLt_L_�� ! pecirKatruns r <br /> Public Other i 1 Delta Depth of Grout Seal 4? *_tLn <br /> of Grout - <br /> Vytrrgletron AfKxos. Depth .- Eastern SuNaca Seal Insia-led by (_ <br /> Repan Work Done I' Type of Pump V��__ H P State Work Done __A-4:e <br /> Well Destruction t ! Wg41 Diameter _f�.`r r Sealing MatenN(top 60'1 <br /> Depth _ „}''j� Fiiler MatwW IBeJuw E"1 <br /> TYPE OF SEPTIC WORK NEW t TALLATION i i M I'Aln AnDIT10N t . DESTRUCTION( INo aephc system permrttM it public sewer is <br /> available wit"2W feet 1 � <br /> Installation will serve: Residence__ Commerc..d Other _ <br /> Number of living units: Number of bedrooms <br /> Chatacter(if soil to a depth of-_feet: --Water table depth <br /> SEPTIC TANG I Type/Mfg ---_ Capacity---- No. Compsrtr+ents <br /> PKG. TREATMENT PLT 1 1 Method of Disposal el <br /> Distarere to••sarest: Wen Feu ndation _ Property Line <br /> LEACHING LINE I ' No A 'ength of lines ._. _. Total <br /> FILTER BED I Diva,ce*o nearest: We11 Foundation Property Lire <br /> SEEPAGE PITS I I D"Teth _ _- Sets _ _-.—_ Number <br /> SUMPS Distance to nearest: well _ Foundatien _ °roperty Line _ <br /> DISPOSAL PONDS <br /> 1 hereby certify that I have prepared this application and that the work will bre done in accordance with San Joaquin county ordinances,state taws, and <br /> rules and regulations of the San Joaquin Local Health Di?.tact. <br /> Home owner n•licensed agent'+aipnature certifies the following: "I cenify that in the performance of the worn t•N which this permit is issued,1 shall not <br /> employ any person in... manner as to become subject•n workmen's conpsnsatron taws of California."Contra, -',t hiring or sub-contracting siWtature <br /> certifies the following:"I certify that in t!M performance of the work to;which this permit is issued,I shell employ pe,wr,s subject to workman's compenrsa. <br /> tion laws of California" <br /> The applicant M)w call for ae requilleted Insspections. Complet+drawing on <br /> Signed X 1L-�L-i. (�_Gla< Th1e. _ter �sr [Jr_�-�t----- Dole: - c <br /> ` FOR DEPARTMENT USE ONLY <br /> Application Aceepted by �brG��� -_ _ Date Area <br /> y ✓ .l <br /> PA or Grout Inspection by /'_` Date _ ` S Final Inspection 1r,'._ 7"r Davey-0__ <br /> Additional COmment3 _ _ <br /> 0 Stk 466 6781 13 Lodi 3b8 3621 L3 Manteca 823.7104 0 Tracy 83t 4XS <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Harelton Ave., P.O. Bow 2008, S1k., CA 95201 <br /> INFO AMOUNT CUE AMOL4T REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> • [N DN ie(V r ♦�� (/�.:'/.� � Ili <br /> r <br />