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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 42 C2 City Lot Size PM <br /> Owner's Name 10 GXJ i/� Address ,� wN��� _ Phone <br /> Contractor .�i.e/i.�!/�L(.;T,- Address l %ed License No. Phone <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS f <br /> _ f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing : <br /> F <br /> ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type of'Casing Specifications <br /> f'1 Public (-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.Approx. Depth I I Eastern Surface Seal installed by _ <br /> Repair Work Done ❑ Type of Pump_r H,P. State Work Done T <br /> Well Destruction ❑ Weil Diameter I Sealing Material Itop 50') <br /> i Depth z Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION "1- RFPAIR/ADDITIO� DESTRUCTION I I (No septic system permitted if public sewer is = <br /> ,� available within 200 feet.i <br /> Installation will serve: -Residence L Commercial — Other <br /> Number of living units: -/—. Number of bedrooms'.1 - <br /> t <br /> Character of soil to a depth of 3 feet: APO Be= Water table depth. t <br /> SEPTIC TANK ❑ Type/Mfg 1?14t141_. Capacity-ZaC?r_l-- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: well -7-4-107 f=oundation /6 Propert" Line_ i <br /> LEACHINGY LINE yu No. & Length of lines, ����} lCt� _ Total length/size <br /> FILTER BED ,a 4 ! "C] Distance to nearest: Well Foundation Property Line ._10rZ <br /> SEEPAGE PITS I I Depth ' Size Number M <br /> SUMPS Distance to nearest: Well / f Foundation t <br /> " : 'd �� _g Property Line <br /> DISPOSAL PONDS"' -CJ'- ' <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 taws, and <br /> rules and regulations of the San Joaquin Local Health Di'strict.j <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+;ork far 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 re fired i s coons. Complete drawing on reverse side. <br /> Signed X 1 -�. - _ Title: Date: <br /> `' s i:• <br /> FOR DEPARTMENT,USE ONLY *-' j <br /> :I <br /> Application Accepted by "n t r + � Date- '� � Area <br /> t P a <br /> ';Pit.or.Grdut�Inspection by Date } Final lnspecfibn bye u "~ Date <br /> yf <br /> kw:Additional:Comments: . t - <br /> ❑ Stk 466-6781 L7 Lidi1:369-3621 ffMa6tecat 823-7104 © Tracy 835-6385 I <br /> Applicant - Return all copies to: Environmental Health Perrhit/.Services 1661 E. Hazelton Ave., P.O. Box`2 CA 95201 <br /> -�� <br /> INFO «'--AMOUNT DUE----•- --AMOUNT•-REMITTED— CK 0 �--RECEIVED'BY"'.,.f_ ­—DATE— 'PERMIT'NO:` Y "" <br /> +.EH13-24 MEV.t i n 51 ~� °�,..• ✓�• . ,,, t,' .�: �y `' <br />