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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES Y 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. j <br /> Job Address 00 ,�)7t <br /> ,. -'q City ► Lot Size PM <br /> RA Owner's Name s � .4E Address eF41_-" .• Sj <br /> Phone <br /> ContractorAd11_Z Address . /-12 M4 License No, a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ , DESTRUCTION LJ <br /> PUMP INSTALLATION El SYSTEM REPA19 0..,+ 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.,of ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy jype'of Casing Specifications <br /> ❑ Public F1 Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> I Irrigation _.-Approx. Depth '4Q Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter ?{' 'r ` Sealing Material (top 50') <br /> Depth 'A -` Filler Material /Below 50') k' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 /REPAIR/ADDITION DESTRUCTION f I (kjo septic systterfi permittecLif public sewer is <br /> av attabte-withi feetr) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of iiving units: 4-- Number�bkbedrdonis"_.'� <br /> 1 <br /> Character of soil to a depth of 3 feet: '-�" � Water table depth <br /> SEPTIC TANK 0 Tyne Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r' Method of Disposal <br /> Distance to nearest:. .' ,Well Foundation Property Line <br /> LEACHING LINE � � No. & Length of lines ' —f Total length/size ' <br /> FILTER BED N`. ❑ Distance'Eonearest- Well e" Foundation, Property Line~ <br /> SEEPAGE PITS I I Depth n Number <br /> SUMPS .' L] Distance to nearest:` ;+r-Well�. _;',-� Fobdation. Property Line <br /> DISPOSAL PONDS, ❑ _j ,•- -- ` <br /> I hereby certify that'I have prepared this abplication and that the work.will be done irk Accordance with Sari Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. '• <br /> /Home owner orrlicehsed-agent's�idnatur6icertifies 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 b4come subject to.-workman's' imus of California." Contractor's hiring or sub-contracting signature <br /> certifies the toAQwing: "I certify that in the performance of the work for which this porrdheis issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for aVeq`uired inspections. Complete drawing on feverse sidt <br /> Signed Title: . .i �r 4�r <br /> bate:Y - <br /> � Ems. ART�hl1ENT USE O LY <br /> t Gr <br /> Application Accepted by �J <br /> ' Data- plcea <br /> Pit or Grout Inspection by Date Final Inspection by- Dat <br /> Additional Comments: <br /> T ❑ Stk 466-6781 I ❑ Lod <br /> 46g-3621 0 Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant=`Reium all copies o: En`virorimenfaa Hee7th'Pe�m;t/Services` 1 E�Hazahon A76.', P.0'Box 2009, Sik., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE pERMIT'NO. <br /> INFO CASH <br /> + EH13-21(REV.I/n s) `, F f �-••7 <br />