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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> f Telephbne (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAWFROM DATE ISSUED <br /> (Complete in'THpkate)` <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 /> j 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 /> I Local Health District. I • M <br /> Job Address r -.L.City �, -Lol'Slze c:j.• �` <br /> //q D1. f`G PM <br /> 1 Owner's Name - GZGf_�.r�xP ;�lf �f�«+ Addrese� r - <br /> �_ Phone <br /> Contract - t Address C.�%T /' License Not Ffione �>�� <br /> TYPE OF WELL/PUMP: NEW WELL !J WELL REPLACEMENT,C-1 y DESTRUCTION L] K (� <br /> PUMP INSTALLATION` ❑ SYSTEM/REPAIR 10 <br /> �~y ,` OTHER G. W <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES j _ <br /> DISPOSAL FLD'—_, PROP. LINE all. <br /> FOUNDATION AGRICULTURE WELL -4-OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARrA-�CONSrAUCTION SPECIFICATIONS <br /> C3 Industrial 171 Open Bottom Manteca di <br /> a. of Well Excavation Dia. of Weil Casing <br /> ❑ <br /> O Domestic/Private G Gravel Pack D Tracy Type of Casing Specifications?` <br /> F1 Public Other C Delta Depth of Grout Seal-� Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump H.P. r State Work Done <br /> Well Destruction 7 Well Diameter Sealing Material (top 50 —. <br /> Depth Filler Material{Below 50`I <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIR/ADDITION DESTRUCTION G (No septic system permitted if public sewer is P <br /> available within 200 feet.) X81 <br /> Installation will serve: Residence_1� Commercial ther <br /> Number of living units:_ 1_ Number of be room$. / <br /> -- �-f <br /> Character of soil to a depth of 3 feet! TI + `�. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity �No. Compartments >' <br /> PKG. TREATMENT PLT. 1 - °•� Method of Disposal <br /> Distance to nearest: Well Foundation , Property Line <br /> LEACHING LINE No. & Length of lines _ <br /> Tn:i Length/size_.' <br /> FILTER BED L Distance to nearest: W,ell_, _ Foundation .:Property-Line <br /> v i <br /> _ 1. <br /> SEEPAGE PITS _U epth �< Size_ X _. umber_ <br /> SUMPS 8 Distance to nearest: Wellr!? Foundation _ IZ9 <br /> _ Property.Lin'� <br /> DISPOSAL PONDS -7 I f <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 agents signature certifies the following: "I certify that in the performance of,the work for which this permit is issued,1 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 compensa- <br /> tion laws of California." t <br /> The applicant st call for all ui� inspections. Complete drawing on reverse ids. <br /> Signed Title: Date: <br /> FO DEPARTMEr USE ONLY <br /> Application Accepted by Gi C� Date, - _(�J Area /-2— <br /> Pit or Grout Inspection by Date�/ Final Inspection by 1;,I, � Date <br /> Additional Comments; <br /> L Stk 466-6781 369-3621 C Manteca; 8237104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permft/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk.,CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED - CASH- RECEIVED BY . DATE PERMIT"NO. <br /> + EH14-2A tflEY.�/3„ <br /> EH 1426 QO � • • d� "t .L <br />