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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZEL 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 <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 /> A G � }' .F <br /> Jab Address �9_6 cSJ��`i.t2i� ,��� City ASC Lot Size 'PM - <br /> wu FrXo4(& d4tV_,FT_ -� <br /> Owner's Name Address .lr_i4rrIOCR" Phone t <br /> "Co�tar,� � G[� Address License No �Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ". <br /> 13 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wd Excavation Dia. of Well Casing <br /> Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1 Public Ll Other `w t, /=/.,Delta Depth of Grout Seal Type of Grout YIJ <br /> .I Irrigation _Approx. -Depth 14I�Eastern Surface Seal Installed by V <br /> Repair Work Done;,'.❑. . SType of Pump` ' H.P. State Work Done_ 0 <br /> Well Destruction El Well f3iamete`r." ^ r`' Sealing Material (top 501 <br /> lJepth ] ''` j Filler Matb'dal (Beldw '1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR7ADDITIONr.I`1--"'UES7RUCTION"ItlArN septic•system permitted if public sewerJs <br /> available within 200 feet.1 g <br /> Installation will serve: •Residence J! Commercial Other S".+' ,• a� <br /> Number of living units Number"bf bedrooms <br /> Character of soil to a depth of 3 feet: 4 '���jr� `' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t -. br.. .� a a, it : A�p�Q.._ No. Com artments t <br /> RKG. TREATMENT PLT. © f F , + Method of Disposal f <br /> Distance to nearest: Well Foundation F Property Line <br /> L°EACHING LINE 1K No. & Length of lines t' _ Total iengttr/:size sem' ` $ <br /> FILTER BED !S1 Distance to nearest: •:-Well p FT Founcdatiorwly Property Line <br /> SEEPAGE PITS I I Depth _�T SizeNumber 7j s <br /> SUMPS Distance.to nearest: Well Foundation iS� Property Liner�� <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that'the work,vOill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District:_~•t,:`' ' _ ;; t <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 df Ceiifornia."Contractor's,'hiring or sub-contracting signature <br /> dertifies 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 compensa- <br /> tion laws of California." v <br /> The applicant must call fo all req red inspections. Complete drawing on reverse side. . �+ <br /> r <br /> ,Signed X Title: l Date: <br /> LORDEPARTMENT USE ONLY <br /> �ppiication Accepted by Date 4 Area <br /> 1 w t <br /> OR or Grout Inspection by Date Final Inspection by Date q 2` <br /> I �A <br /> l,#dditional Comments: .• <br /> L Stk 466-6781 Ltidi -369-3621" ._❑ Manteca 823-7104 © Tracy 835-6385 <br /> /,lpplicant - Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> FEE AMOUNT DUE AMOUNT REMIrrrO CK RECEIVED BY DA , PERMIT'NO. <br /> INF11 <br /> O CASH r� <br /> +-EH-,3'2CARCd1-• I �, •�7V I`V . ( { 'j F' [ air 4� <br />