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-- I <br /> APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 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 1 <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 /> I <br /> " <br /> Job Address City . Lot Size -! al PM <br /> Owner's Name +V Address �....�� J �"'""'aA� �r Phone <br /> I <br /> Contractor Addre ss 'Z� ,pC �� License No. 03 Z Phone� � <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> CE TO EARL -ST :_ SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> DISTANCE <br /> �� FOUNDATION AGRICULTURE WELLC`` OT.HER WEl,'b PITS/SUMPS <br /> _ - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 6Dita. of Well Excavation, Dia. of Well Casing <br /> iI �' "� � -., Specifications i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of_Casing-^I ^-- P <br /> {-1 Public ❑ Other Cl Delta 'Depth oftGrout Seal Type of Grout <br /> i L Irrigation- —.Approx. Depth I I Eastern Surface'Seal Installed by <br /> Repair Work Done ElType of Pump H.P. rF-`i; _Ste et Wo�kk D � f.,,q ✓ <br /> Well Destruction 11 Well Diameter Sealing Material,itop 50,1 ti <br /> Depth _Filler Mai a! ,Belo 1 ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADfV DESTRUCTION I I iNo septic system'permittgd if public sewer is <br /> _ available within 200 feet./' - <br /> Installation will serve: Residence Commercial_ Other r 1 y lJJ <br /> Number of living whits: Number of b cims`� y J V' <br /> Character of soil to a depth of 3 feet: I '���f Water table depth <br /> SEPTIC',TANK ❑ Type/Mfg• . Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 �-1 "� € / Method of Disposal _ <br /> Distance to n reit: Well " Fpurifatttsn - Property Line <br /> ' - -_ f Total len r <br /> LEACHING LINE .�NOrfX Length of lines length/size <br /> 9 <br /> FILTER 113E 1) ❑ Distance to nearest: Well Foundation 0( Property Line 5� <br /> SEEPAGE PITS 6-r' Depth t' Size Z16 rl p Numberl <br /> SUMPS, 0 Distance to nearest: Well I�W1 Foundation a Property Line / 11 <br /> �DISPO AL 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 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 componsa- <br /> tion laws of California." <br />' The applicant rRust call f r all quired inspections. Complete drawing on reverse side. <br /> Signed! //1 Title: .d W AA Date: <br /> A FOR DEPARTMENT USE ONLY <br /> Applicadlion Accepted b Date Area F <br /> Pi or Grout Ins do _ Date R Final Inspection by D to 6 <br /> id <br /> L <br /> Additiorial Comments: ,-) t7 G <br /> ❑ Stk -4781.-... 01^di__369:3621L..__1-Manteca_.823_7104 Manteca-823_7104-0-Tracy,_W5-6385- <br /> Applicant - Return all copies to:+Environmental Health Perrin-iRServicess1.601 E"'Hazelton Ave.,'P.O. Box 2009, Stk., CA 95201 I <br /> FEE AMOUNT DUE' AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. <br /> INFO ^�/ <br /> +.EH 13-24 IREV.i n 51 f <br /> EH 14-26 <br />