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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE` ON AVE., STOCKTON, CA <br />Telephone 4209) 466-6781 <br />PERMIT EXPIRES 'I "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 instaff the worlIt herein described, This application is <br />made in compliance with San Joaquin County Ortrmance No. W for sewage or No. 18V for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District, <br />i I %A�,­l <br />Job Addrllla��2___Iez 45,_ - city Lot Size <br />_C Owner's Name Phone <br />�,, Address <br />Contractor's Name Phone <br />License No, <br />TYPE OF WELL/PUMP: N WELL i_,; WELL ]REPLACEMENT Ci DESTRUCTION 0 <br />PUMP INSTALLATION 0 SYSTEM REPAIR L.' <br />DISTANCE TO NEAREST: SEPTIC TANK <br />— SEWER LINES — DISPOSAL FLO._ PROP. LINE <br />FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUM S <br />INTENDED USE <br />n <br />0 DorrsasaClPrivaYe <br />C3 Public <br />E Irrigation <br />Repair Work Done <br />Well Destruction C: <br />TYPE OF WELL <br />Li Gravel Pack <br />Other <br />__A4Vrox. Dopth <br />Type of Pump <br />Well Diameter <br />Depth — <br />PR08LEMARF-A CONSTRUCTION SPECIPCATIONS <br />5 Manteca I , Dim, of Well Excavation . ......... <br />_1 Tracy 1 Type of Casing - <br />01 Delta— --'—Depth of Grout Seal <br />LJ Eastern Surface Seal Installed by, <br />H.P. State Work Done <br />Sealing Material (top SO') <br />Filter Material (Below 50'1 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION C, REPAIR/ADDITION C DESTRUCTION 0 (No septic system petmfttee <br />available within 200 feet.) <br />installation -,*All aarvc- Residence _ Commercial — Other <br />Number of living units. — Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK <br />J?11^TyPe/Mfv No. Compartments <br />PKG. TREATMENT PLT, C: Method of Disposal <br />Distance 10 nearest: W841 FoundationP,operty Line <br />Dia, of Well Casing <br />Softifiorions <br />Type of Grout <br />LEACHING LINE No, & Length of lines Total length/size 9 <br />FILTER BED Distance to nearest: Well _T2.e4Z__ Foundation_Z&4_Zet: Property Line <br />sewer is <br />til <br />SUMPS C-1 Distance to nearest: Well, Foundation _—Z _40,�fsroperry Line <br />DISPOSAL PONDS 11 <br />f I hereby carilfy that I have prepared this application and that the work will be done in accordance with San Joaquin cou" ordinances, state Iem, and <br />rules and regulations Of the San Joaquin Local Health District. I I <br />Horne owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is inued, I shall not <br />arriployany person in such manner as to become subiact to wotknnian's comotknsafton laws of California." Contractor's hiring or sub -contracting signature <br />cer6l*s the following: "I certify that in the performance of the work for which this permit Is js*ued, I shall 6ME90Y Persons subject to workman's compensa- <br />tion laws of California." <br />The applicant must CO for ail required inspections. Complete drawing an riaverw side. <br />Claw –,2 .3 <br />7 <br />Signed X_____4� <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by <br />---- ------ Date Area <br />Grout Inspection by -on by <br />I I Date Finial Inspect, Date <br />Additional Comrnenis: <br />C Stlk 466-6781 0 Lodi 369-3621 13 Mantem _OTracy 835 -SM <br />Applicant - Return all copies to: Ejrwironmental Heafth Permit/Servicas 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA SMI <br />EH 1324 (REV. to"to <br />EM ?4-26 <br />FEE <br />!FAMOUNT DUE <br />_;.IEr-EO <br />AMOUNT REMITTED <br />CK a <br />CASH <br />RECEIVED BY <br />DATE <br />KRIVIrt, W. <br />