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C <br /> 3 <br /> _ APPLICATION FOR PERMIT <br /> .+ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501 E. HAZE'LTON AVE., STOCKTON, CA <br /> Telephone (209) 456-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t✓o� ��� <br /> (Complete in Triplicate) -ro 1-7-7P- <br /> Application <br /> 97P- <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 fJ/._•rG S, /?JC K/.tl� i/__- City ��4C, Lot Size —3 4 PM ' <br /> Owner's Name A 1 C Address 2 303 RM!5 t S4 aJ7— 2 !!AJ Shone 1­73-194_f <br /> -Contractor <br /> 73—J94.fContractor F4=9* �! PLX"D Address;7 Al, A DE 4- i6"i License No. 76 Phone d'�97/ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 TYPf OF WELL PROBLEM'A'REA"- CONSTRl7CTION SPECIFICATldNs� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public Cl Other Cl Delta Depth of Grout Sea! Type of Grout <br /> RI I Irrigation r .Approx. Depth I 1 Eastern Surface Seal Installed by <br /> 5 Repair Work Done. ❑ Type of Pump H.P, State Work Done <br />�f Well Destruction ❑ Well Diameter- Sealing Material (top 50') <br /> v <br /> Depth' Filler Material (Below 50'1 . <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION REPAIWADDITION I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.► <br /> Installation will serve: Residence Commercial_____ Other <br /> Number of living units: _L -Number of bedrooms _-.__..__ $ <br /> Character of soil to a depthh of 3 feet: ,5A AJ E> Water table depth <br /> SEPTIC TANK C Type/Mfg —Pfk4 Capacity 1 Zd o No. Compartments �-- <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well �4 Foundation /Q r Property Line__/4 ' <br /> LEACHING LINE L'T No. & Length of lines 7d Tota! length/size - 10 <br /> FILTER BED ❑ Distance to nearest: Well Foundation I.< Property Line, <br /> SEEPAGE PITS 1 1.r Depth Size' Number <br /> SUMPS ❑ Distance to nearest: Well `� Foundation Property Line <br /> DISPOSAL PONDS , ❑ <br /> I hereby certify that I ha-ve prepared this application and that the work will'be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations ofJhe San Joaquin Local Health District. <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 became 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." <br /> r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: _-. -bale" <br /> J Ji n EPARTMENT USE ONLY <br /> Application Accpied byaM niy,, ,,_...-_ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date I <br /> �7� Q� } <br /> Additional Comments: � � �' />' LC.cz C.� L-a...� 1� �.: -hr G <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Sere 1 1 E. zelto Aye., P.O. Box <br /> FEE OUNT DUE AMOUNT REMITTED CK411 <br /> RECEIVED(3Y DATE PERMIT NO. i �ttar%� <br /> INFO CASH <br /> EH13-24 IREV-t i H 51 (�,. O C� <br /> EH 14.28 _ <br />