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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> I' PERMIT EXPIRES TYEAR 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 /> I 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 !77X ALUVIEW CTL City Lot Size PM_ <br /> HOA <br /> Owner's Name <br /> Address �f l�f 7 Phone me�`� �- <br /> #4y— <br /> Contractor C L4VA - 0AUAIrAddress 94V5. 1« License No.(V2af:Z PhoneC27 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ <br /> -DiSTANGE TO-NEAfREST:TSEPTIC TANK `SEWER LINES" "'" --j-4.DISP_OSAL.F.L!].ZaZeEL-PRO.P_._LINE;:ZQ�_,� <br /> FOUNDATION "' AGRICULTURE WELL' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation IAI Dia. of Well Casing <br /> .Domestic/Private `.Gravel Pack- "ATracy Type of Casing P � - /en pecifications <br /> F] Public Cl Other 171 Delta Depth of Grout Seal. Type of Gro' _ <br /> I Irngatipn --Approx. Depth I i Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ r <br /> Well Destruction ❑ Well Diameter Sealing Material (top SO') '�•} <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l ) DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet./ G <br /> Installation will serve: Residence _Commercial_ Others Y _ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> E r--SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ y `, Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> k LEACHING LINE ❑ No. & Length of lines Total length/size rn <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line:: <br /> l - SEEPAGE PITS I I Depth Size _ Number <br /> � _SUMPS�­ �" L7x'�Disiarice—to nearest': "�'Well ' "° undation"'°° Property`Line <br /> 1 DISPOSAL PONDS D > <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 Ds%trict. <br /> k 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 certi 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 applican t fo II req Ar ins ctions. Complete drawing on re ase side. �_ v <br /> Signed X r Title: Date: <br /> FOR DEPARTMENT US NLY <br /> Application Accepted by <br /> y Date V/ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi -3621 anteca 823/7104 Tracy 835-6385 +- <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> ♦.EH13-24(REV.I/H5) �O �/ 4q0O 7nEH 14-28 <br /> f <br />