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APPLICATION FOR PERMIT <br /> SAN`JOAQUIN,LOCAL,-HEALTH DISTRICT <br /> s 1601 E. HAZEL T ON AVE., STOCKTON, CA �— <br /> a, Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) v L <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 a ./..�; f - ='i r J t• aN �,? f�.� <br /> City Lot Size PM <br /> Owners Name aAddress r,R t <br /> — -- Phone f �, <br /> Coritractarf . Address t�• ' i. License No. Phone <br /> TYPE OF <br /> LL/PUMP—NEW WELL ❑; WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP;INSTALLATION ❑. . .SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: _SEPTIC TANK " SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER <br /> .VV PITS/SUMPS _ <br /> INTENDED USE --—TYPE BLEM AREA ..CONSTRUC ECIFICATlONS <br /> ..,: ❑ Industrial,,,:,.....;; ❑ Open Bottom ❑ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ racy Type pf Ca� ""in9Specifications <br /> .Y M Public []'Other l " a Depth of Grout Seal '"* <br /> p Type of Grout <br /> .I I Irrigation ,, _.Approx. D I I astern. Surface Seal Installed b <br /> Repan€ W06. Dc;rw. (At Type of tp �. _ H.P. ;at rl Done _ <br /> Well Destruction D;; DiameterOT Ing MatariaC top ' <br /> Depth Pillar Material [8elow 50'1 <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION I] RE AIR,/ADDITION 1.1 DESTRU TIO a eptic system permitted if public sewer is <br /> va a within 200 feet.) <br /> it bl , <br /> Installation will serve: Residence Commerci Other? <br /> } Number of living units. Number of bedroo s <br /> Character of soil to a-depth of 3 feet)" ater table depth <br /> i SEPTIC TANK ❑ , Type/ Ca acrt { ' <br /> p . y o. Compartments <br /> PKG;TREATMENT PLT 0' I ethod of Disposal <br /> # Distance to.nearest. i ProO y Line <br /> LEACHING LINE ❑ No. & Length of Eines.; p T / 1ze <br /> r ;;.•. FILTER BED ; 5 El Distance to nearest: -fLL Well j Foundatiori rty Line ' <br /> SEEPAGE PITS i I«' Depth Size Number r <br /> a cr SUMPS Y:l fl >.Distance`to nearest: Well Foundation Prop rty Line <br /> 1 DISPOSAL PONDS O` <br /> ? i hereby certify that i have prepared this application alt that the J ork will br, ordance with S n Joaquin county ordinances; state laws, and <br /> rules and regulations of the San Joaquin-Local Health <br /> Home owner or licensed agent's signature certifies the oIlowmgC''I'certify that in the performance of the York for which this permit is issued, I shall not <br /> a ! employ any person,in such manner as to became subje t to workman's compensation laws of.California." ontractor s hiring or sub-contracting signature <br /> ,- certifies the following:"I certify that in the performance f the work for which this permit is issued,I shape play parsons subject to workman's compensa- <br /> tion laws of California." I <br /> i - The applicant must call for all required Finspections. C plate drawing on reverse side <br /> r s Signed X Y ,.d .. Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �, Araa Y <br /> Plt or Grout Inspection by . ate Final inspection by I Date / <br /> D 5tk 466 '.. <br /> j Additional Comments k.11 i �. J�t b [ �t ..; p . <br /> 6781 + odi.. 369-3621 _..❑ Manteca 823-7104._ , 11 Tracy .,835.6385,.." <br /> g1 Applicant :Return all'copies to: Environmental Health Permit/Services 1601 EHazelton Ave., P.O. Box 2009'Stk.', CA,95201 <br /> FEE AMOUNT.DUE AMOUNT REMITTED GK RECEIVED BY' <br /> 1 INFO Ag DATE PERMIT N0.' <br /> r <br /> r EH 33"24[REV.1,n 51 <br /> s EH 14,2e <br />