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t APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCK.TON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ^ <br /> Appfisation is hereby made:=the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in cpmplianco with San Joaouin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anti Regulations of the San Joaquin 5 <br /> I <br /> Local Healh District. <br /> :I <br /> Job Address �AZ2&!rA/,l n et.. C:ty A 14, Lot Size PM <br /> Com, ` �� � / } , <br />'r Owner's Name p CQ I Address ._.Ld rz c t�L� Phone fly,- <br /> l (t`{ 9c c;rpg r <br />+ Contractor �� & firma C/LVA Address 4WV7//i(Ji License flo.-26ffllsC�. <br /> TYPE OF WELL/PUMP: NEW WELL ❑-. WFILL REPLACEMENT Cl DESTRUCTION ❑ <br /> y PUMP INSTALLATICn1 0 SYSTEM REPAIR 0 OTHER 5c4I �°Lt <br />>` Dl;•;-'NCE TO NEAREST: SEPTIC TANK SEWER LINES —. - !DISPOSAL FLD. POOP, Ll,.'-!E <br />'' S� 4iAl eiic[tr g� FOUNDA':ON AGRICULTURE WELL _ OTHER 1:-.ELL _ PITS/SUMF-S <br /> r INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑open Bottom 0 Manteca Dia.of WEI1 Excavation " _ Dia.of Well Casing _ <br /> r � <br /> D Oame.stic/Private L-1 Gravel Pack ❑Tracy Type of Casi,tgY Speclfli;ations � <br /> f.`Public 171 Other q Delta Depth of Grout Seal 2.W 44 Typo of Grout& \y <br /> i. I-Ilrrigation �Approx. Depth - I I Eastern Surface Seal Installed by <br /> 3. Repair Work Done 0 Type of Pump H.P. State Wcrk Dane <br /> t Well Pestruct:on 0 Well Diameter __ Sez;iing Material (top 50') <br /> 4 <br /> SO Ys<SGlr^{rnQ Depth_ Filler Material(Below 501 <br /> TYP6,QF SEPTIC WORK: ,NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system peimitted it public sr.M s' 3 <br /> - available within 200 feet..) i <br />° instal Trion v ill se - Residence Commercial Other 0: <br /> Number of living units: umber of bedrooms <br /> Character of soil to a depth of 3 feet: — e,e abie depth <br /> SEPTIC;TANK 11 Type/Mfg Capacity No.Compartments _ <br /> PKG:'TREATMENT_PLT. ��; Method of Disposal <br /> Distance to nearest; Well alit"__Y Property Line <br /> LEA-HING LINE Cl No.&Length of lines length/size <br /> FILTER BED LI Distance topea, sit: Well Foundation Pro Line <br /> SEEPAGE PITS J_--r-r Depth.^ —Size Number -- <br /> SUMPS L], Distance to nearest: Well Foundation Property Line <br /> SAL POwl <br /> am— DS d <br /> hereby cenify khat I have prgpared this application and that the work will be done in accordance with San Joaquin county ordinances,stela laws,and <br /> rules and regulations of the San Joaquin Loyal Hezfth District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performane9 of the work for which this permit.';issued,I shall not <br /> employ any person in such manner as to become subject to.workman's compensation laws of California."Contractor's hiring or sub-contracting signatura <br /> certifies the following:"I certify that in the porformance of the work for which this permit is issued,I sh0;employ parsons subject to workman's compensa- <br /> tion laws at Caiifar ' { <br /> Tt,e applicant m t c II�allq uir ins tier omplete drawing on reverse side. �-�jqu e 111e&,Wzd) <br /> Title: <br /> R USE ONLYice. Date: J <br /> g <br /> o- Application Accepted by _ _ Data Area qy <br /> Pit or Grout Ins Fac' Date Final Inspection by Date M, / U7 <br /> Additional Com ts: <br /> 0:Stk -066-6781 f] Lodi 369.362T: C." Manteca 623.7104 ❑Tracy 8356385 <br /> Applicant -Return all copies io: Environmental Health Permit/Serviv as 1601 E. Hazelton Ave., P.O. Box 20W,Stk., CA 95201 �r <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT-NO. � <br /> INFO, ASH <br /> r ER 13.24(REV,I/rryr <br /> j EH 1428 �r. <br /> P. <br /> 4ntawa�aerramo'r� <br />