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i <br /> APPLICATION FOR PERMITVY <br /> USAN JOAaU1N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., <br /> STOCKTON, CA <br /> I' Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Joaquin No.549 for sewage or No. 1f362 for we111pump and the Rules and Regulations of the San Joaquin e <br /> Application is hereby made to the San oquin Local Health District for a permit to construct and!°r in the work herein described.This application!s <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. PM <br /> 0� t ip �t� i-�C) CitY G Lot Size <br /> Job Address <br /> -23 3 r_. i _ <br /> 14G Phone <br /> ,s �e><e. 0rVn q& Address <br /> Owner's Name �f <br /> �,f(r {� C Address <br /> p� d License No. Phone <br /> Contractor ��-`"�J��' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 11 NEWrWELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP. SYSTEM REPAIR ❑ <br /> i PUMP INSTALLATION ❑ DISPOSAL FLD.— PROF. LINE <br /> I I SEWER LINES ---- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANKi�--� AGRICULTURE WELL OTHER WELL— <br /> FOUNDATION!�--- <br /> INTENDED USE TYPE OF WELL PROBLEM E'4 CONSTRUCTION SPECIFICATIONS D{a of Wel{ Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Specifications <br /> ❑ Industrial I p Tracy Type of Casing y <br /> ❑ Dome ❑ Gravel Pack'! Type of Grout <br /> [:1 Other n Delta• Depth of Grout Seal <br /> ['1 Public Surface Seal Installed by <br /> I l 1rrlUation �..Approx. Depth i I Eastern State Work bone <br /> ' H.P. <br /> Repail Work Done L1 Type of PUMP Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter,- <br /> — ' <br /> Depth I 1 Filter Material (Below 50'1 r+I <br /> REPAIRIADDI7ION I l DESTRUCTION I I alvailaWE <br /> blerwThin 200 feet.) <br /> blum ed rl public sr wor is l! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION . <br /> installation.will serve: .Res!dcommercial Other <br /> Residence �' <br /> Number of living units: <br /> Number of. edrooms Water.table depth <br /> Character of soil to a depth of 3 feet-..FfG I�¢ No. Compartments <br /> , • CapaCilYt.�n <br /> SEPTIC'TANK I�"TypelMlg Method of Disposal <br /> PKG. TREATMENT PLT.❑ f( [ '1 Foundation Property Line (' <br /> Distance to nearest: Well UU, <br /> —/ Tlal length/size <br /> LEACHING LINE IX No. a Length of lines Property Line `D <br /> © Well_ Q— Foundation: <br /> FILTER BED Distance i:1 nearest: S i <br /> i j'I Sizo ' ,. Number <br /> l SEEPAGE PITS I I Depth Property Line SUMPS Ll Distancoi to nearest: Well <br /> Foundati6h'---J--�--�- (� <br /> -' DISPOSAL PONDS ❑ �� <br /> certify that I have prepared lNis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and �1 <br /> hereby ce y i. <br /> rules and re ulations of the San'Jaaqurn Local Health Dilowin. <br /> I is <br /> g g: .' Y <br /> Home owner or licensed agent's signattirbecome subject workman'sHcompensation performance <br /> California."Cantract°work for�srhiri g othis psub <br /> ermt-contracting1lsignature <br /> employ any person in such manner as to <br /> _ certifies the following: "I certify that in;ihe performance°f the work for which this permit is issued,!shall employ persons subject t°workman's compensate <br /> tion laws of California." <br /> The applicant must call for all re uired,inspections. Complete drawing on reverse sid©. Dater <br /> Title: <br /> Signed <br /> FOR DEPARTM NT USE ONLY 7 <br /> Date Area / <br /> Application,Accopted by4 Date AW <br /> I } Date Final lnspecti°n by <br /> Pit or Grout Inspection by <br /> Additional Comments: 0 Tracy <br /> El Stk ' 466-6761 I'0�l 3W-362 ntal HnealthaPeermitlGO Senn eQs 1601 C. Ha alt n�Ae., p..0. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Env ironme <br /> ( CK RECEIVED BY DATE ;MLNO. <br /> IFEEbtiE - AMOUNT REMITTED GASH <br /> 5 INFO AMOUNT <br /> A <br /> YJ C), DD f�- O <br /> a.f -26 <br />