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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 EXPIq:ES�"i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heraby made to the Sao 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 /> r Job Addressr � '� <br /> Gty _ Lot Size__ �✓ /7� , <br /> Owner's p{ : <br /> � _ l� IV� r���. . }oma,,f 376 <br /> Nam tCd�es±i - <br /> Phone <br /> Contractoris Address • L S7I� <br /> License No. _Phone <br /> TYPE OF WELUPUMP; NEW WELL El WELL REPLACEMENT f DESTRUCTION ❑ <br /> PLUMP INSTALLATION 0 SYSTEM REPAIR G OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES <br /> DISPOSAL FLD. T+IgOP, LIQ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial t ❑Open+Bottom ❑'Manteca pia, of Well Excavation <br /> Dia. of Well Casing <br /> C.Domestic/Private ❑Gravel Pack E7 Tracy Type of C"n <br /> • r f�Public f7 Other g Specifications , <br /> C?Delta _ Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx"Oepth I 7EastamSurface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. _ _ State Work Done —Well -- <br /> Destruction • O: Wall Diameter g � <br /> r Sealing Material{top 50') _ •V <br /> r Depth _' Filler Material(Below 5p'I <br /> TYPE OF SEPTIC <br /> WORK: NEW INSTALLATION f7 fiEPAIRJAOOITIt)N ut;b I RUCTION I ; IINo septic system permitted-it <br /> f Public server is <br /> 1 available within 200 feet.Y �1 <br /> "# InsralJation will serve: Residence.=' Commercial Other` i{ <br /> Number of tiving units: Number of bedrooms <br /> Characteri soil to a depth of 3 feet:' l I <br /> SEPTIC TJkf - • • Water table depth <br /> ❑ Type/mfg - <br /> Capacity—,PKGTREATMENT PLT_❑ t No. Compartments <br /> , <br /> Method of Disposal <br /> C?islance to nearest: Well.• Foundation ...__ Property y rt Lute <br /> . pC. <br /> LEACHING LINE No. &Lengtfi of I.'rctes _ N <br /> FILTER BEDTotal length/size _ rT <br /> Distm eft to mazest. Foundairo <br /> Wali r <br /> • n Property Line <br /> SEEPAGE PITS <br /> I I Depth Size isturrtfxer <br /> SUMPS 0 Distance to nearest: Weil <br /> DISPOSAL PONDS 0. Foundation Property Line' <br /> I hereby certify that I have prepared this application and that the work will be,done in accordance with San J 1 <br /> rules and regulations of the San Joaquin Local Health District equin county ordinances,state laws, and <br /> Home owner or licensed agent's signature certifies the,foi owing• "I certify that in the performance of the work for which this permit is issued, I shall riot <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 /> certif ss the following;"I certify that in the Performance of the work for which this permit is issued,I shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all req <br /> uir in ons.Comple swing on.,reverse side. <br /> K <br /> Signed X .. <br /> y <br /> Title: t Date, <br /> r` _ <br /> FOR DEPARTMENT USE OIIILY m <br /> Application Accented by ti(A n <br /> Date --1 Area <br /> Pit ar�Grout Inspection by Da-*� ; T 2 <br /> Final'Inspection by DateAdditional Comments: fZ� t h <br /> ❑.Stk 466-6781 �, 369-3e2j <br /> t <br /> 'Applicant-"allum air 0 Manteca 823-7104 ❑Tracy 836-6385 a^c'I?r r2 I <br /> copies to: Environmental Health Permit/Services.7601 E. Hazelton Ava., P.O. Box 2009, Stk., CA.p*1 <br /> VaE <br /> +' s <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH J RECEIVED BY r DATE Pf rtMtTNQ. <br />