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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> k <br /> (Complete in Triplicate) r <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 /> Jot)Address ,5• i=Avas City L4?72 _ Lot Size 24- PM <br /> Owner's Name w! Address SApt? — Phone —� -� <br /> Contractor "FAD j5. 14100 Z>. _Address 7 Al, APa,_w.-A License No.4Y7ra Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ „- TRUCTION ❑ _, <br /> PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICU E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ar teca Dia. of Well Excavation Dia. of Well Casing <br /> [7 Domestic/Private 11 <br /> Gravel ❑ Tracy Type of Casing Specifications — <br /> M Public ❑ n Delta Depth of Grout Seal Type of Grout <br /> 1 Irrigation l I Eastern Surface Seal Installed by <br /> Repair Wark Done ❑ TyH:P. State Work RoneWell Destruction ❑ WSealing Material (top 50'] <br /> Depth Filler Material (Below 501 `1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR)ADDITION DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.I �t` <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: __.,>✓.."..-_. Number of bedrooms /3 <br /> t <br /> Character of soil to a depth of 3 feet: SZ/0 �° Water table depth <br /> SEPTIC TANK ❑ Type/Mfg &.k/:5 y K.- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal,' <br /> x Distance to nearest: Well Foundation Property Line .f <br /> LEACHING LINE No. & Length of lines—p Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation- -Z.r� �. Property Line .7—a <br /> a <br /> N _ <br /> SEEPAGE PITS .14 Depth Size <br /> SUMPS Ll Distance to nearest: Well 10t4 Foundations ,Property Line 2'0 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 XTitle: eir i Date: <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �` -- Date ". —"�/�Z 92 _ Area <br /> f �� _f� <br /> ay_ Date <br /> Date Final tns�ection b <br /> &FPqi' <br /> -or Grout Inspection by7 . p Y .� <br /> Additional Comments: 1)6 <br /> f <br /> Cl Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 1323-7104 © Tracy 635-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO // C/A�f{SH <br /> + EH 13-24 IHEV.S/H 51 ®.V////4 U ;V, /ISP V ! �f J-1 I ' <br /> EM 14-26 <br />