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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � TM <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I' Telephone (204) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 <br /> (complete in Triplicate) application is <br /> Joaquin Local Health District for a permit to construct and/or <br /> d/ r �d the Rules and Regulatiwork herein on of the San Joaquin <br /> Application is hereby made to the San q Ordinance No.549 for sewage or No. 1862 for <br /> pp <br /> 4 made in compliance with San Joaquin County <br /> Local Health District. � PM <br /> City Lot Size Q <br /> Job Address ' 3 /Phone �° �q(3 <br /> Address <br /> )wner's Name :�, 3 ZZCp Pharie Ic <br /> Fyr ry t t�G= ► O 07� (� License No.• G <br /> Address <br /> GonVactDESTRUCTION ❑ <br /> NEW WELL LJ SYSTEM <br /> REPLACEMENT ❑ OTHER 13TYPE OF WELLIPUMP: SYSTEM REPAIR C1 <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> SEWER LINES PITSISUMPS <br /> j-I.,DISTANCE TO'NEAREST::SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> yFOUNDATION <br /> INTENDED USE TYPE OF WELL PROBL CONS7RUCTkON SPECIFICATIONSDia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> 11industrial ❑Tracy Type of Casing <br /> ❑ Domesticl Private ❑ Gravel Pack Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> + ❑ PublicSurface Seal Installed by <br /> ❑ Irrigation �pProx. Depth ❑ Eastern State Work Done— <br /> e of Pump H.P. <br /> Repair Work Done ❑ TYP Sealing Material (top 50') , <br /> Well Destruction ❑ Well Diameter — . r Material (Below 501 ec C <br /> Depth <br /> available 200 feet`} <br /> TYPE OF SEPTIC WORK: NEW IN57ALLATION ❑ REPAI DDiTION DESTR lCTION ❑ ava(No septicem permitted if pu 1c sewer i <br /> installation will serve: Residence <br /> Commercial <br /> Number edro ms r Water table depth jo <br /> Number of living units:��-- _ l <br /> Character of soil to a depth of 3 feet: - Capacit��� No. Compartments t <br /> SEPTIC TANK Type lMfg Method of Disposal <br /> PKG. TREATMENT.RT. ❑ Foundation_ - Property Line <br /> 3=. <br /> ' Distance to nearest: Well Q <br /> 1 <br /> -_Total-length/size <br /> LEACHING LINE ❑ No. & Length of-Iines_w---.--- - - --" property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation��- r <br /> Numa <br /> SEEPAGE PITS g?"o Depth5 —Size r - property Line_ — <br /> Q Foundation <br /> SUMPS E71 Distance to n��rest: well <br /> DISPOSAL PONDS - ❑ _,_ <br /> ' I hereby cert that I have,prepared this application and that the work will be done;n accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the Joaquin Local`Health District. „l certify that in the performance of the work for which this permit is issued, l shall not <br /> signaturf <br /> Home owner or licensed agent's signature certifies the following: of-California. <br /> employ any person in such�nthat n the perfoemanSubject <br /> ce of he work for wh ch tfiSs tperm tws issued,I shall employ persons lsubje tto workman's compensa <br /> certifies the f61lowing:"I certify <br /> t tion laws of Califor �. . `r 4 <br /> ;i .-The applicant m call for all"re 'red ' spections.�Complete draw;ng on reverse _ e• Date: <br /> * Title: <br /> —Signed-9c} •x._ ,� i <br /> -'-.M-.,....FOR DEPARTMENT USE ONLY <br /> '` �?,- 2� Area <br /> r _ Date_ <br /> Application Accepted by �r / ._ .. D; <br /> Date V Final Inspection by _ <br /> or Grout Inspection by, <br /> Additional Comments: _ --- <br /> ❑ Stk 4664M1 ❑ Lodi 369,3621 ❑ Manteca 1'123-7104 U Tracy 635 6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E.}HazeltonAve., P.O. Box 2009: Stk., CA 95201 <br /> i CK PERMIT NO. <br /> D ..t r RECEIVED'BY DATE <br /> AMOUNT DUE;(� AMOUNT REf4lITTED .--CASH } <br /> INFO g7- Z- <br /> 13.241 REV.11 �c � �.� <br />