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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCALS HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> j Telephone 42091 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 described. This 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 Jg �� E_ `1= .bzP_� +aev�.. City��.Ocl Lot Size f9c&45_S PM. - <br /> Owner's Name On!` Address -ZT77[.xw- � ., Phone <br /> 1944,_ 1 <br /> contractorAIUZ1914 1;—CM2%K . Address2" 10490 IICI1l License No..X�42^,?Phone_-947 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 2 DESTRUCTION ❑ <br /> -- UMP-INSTAL•L-ATION-E -8YSTEM-REP;4'1R`C7� m OTHER-0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t;INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i ❑,industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation k Dia. of Well Casing <br /> ❑ Domestic/Private ElGravel Pack ❑ Tracy ;; , Type of Casing Specifications <br /> ❑;Public d ❑ Other LlDelta Depth of Grout Seal'�s"`� " Type of Grout n. <br /> ❑{Irrigation ---Approx. Depth El Eastern Surface Seal Installed by } ' <br /> Repair Work Done ❑ Type of Pump H.P. y State Work Done frj` <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material iBelaw 50'1 —�� t <br /> r , <br /> o P <br /> • <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION C] (No septic system permitted if public sewer is <br /> I * ,F y, available within 200 feet.I <br /> Installation will serve: Residence Commercial—_ Other <br /> Number of,living units:�_ Numbe of bedrooms ,T „T_- <br /> Character of sail to a d'epih.of 3 feet:f `i`Rz ter-table table depth �� <br /> l � SEPTIC TANK ❑ Type/Mfg) `" t Capacity s, ! No. Compartments <br /> PKG. TREATMENT PLT. ❑ r f Method of Disposal <br /> t � _ Distance to nearest: Welll Foundation --Pr pverty Luis <br /> t LEACHING LINE ! No. & Length of lines - m /EIO Total.length/size <br /> C s FILiTER BED ❑ Distance to nearest: Well--tad Foundation /490 Property Line <br /> I SEEPAGE PITS i0 Depth 2�� Size ,� I Number <br /> SUMPS El: Distance to nearest: Well 100 t Foundation LOO Property tine SO <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will beedone in accordance with San Joaquin county ordinances, state laws, and <br /> t rules and regulations of the San Joaquin Local Health District--, _ � <br /> Home owner or licensed agent's signature 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: ''I certify that in the performance of the work for which this permit is issued, I.shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed 'Title:. Date: 49✓'A(. <br /> FORD ARTMENT USE ONLY <br /> Application Accepted by $ Date < • �� Are <br /> p Pit or Grout inspection by __.., Date = f=inal Inspection by Date `/ v <br /> R + Ys iy. vL. <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 odi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 <br /> o <br /> Applicant- Return 811 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 3 . INFO AMOUNT DUE' AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> E <br /> + EH 1 <br /> 3-24(REV.iia 5) -7o.00- - V0 <br />