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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone f209) 466-6781 <br /> PERMIT EXPIRES 1 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 /> rnade in Compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rulus and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address \y`4N ,JSOt►-+ -- City -. Lot Sire PM <br /> Owner's Narnt: t• Address /� �� �l�,. <br /> � ^i� -Pww�v__ <br /> `'V�,*r�— 'Tt4GR.��►�..tire� _ Pl,or,u3.�- <br /> Contractor� _. Address A • License No. �¢ Phone <br /> TYPE OF WELL/PUMP EW WELL F. WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION C SYSTEM REPAIR i� OTHFR O ; <br /> DISTANCE TO NEAREST_ SEPTIC TANK SEWER I INES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL t PROBLEM AREA CONSTRUCTION SPECIFICATIONS y <br /> Industrial © Open Bottom U Manteca Dia. of Well Excavation Dia-gt Well..Casing_. <br /> 7GL Domestic/Private ❑ Gravel Pak 0 Tracy Type of Casing _ V Specifications <br /> Public (1 Other I Cl Delta Depth of Grout Seal _ Type of Grout _- <br /> i ( Irrigation __Approx. Depth` t I Eastern 4-Surface Seal Installed by, <br /> Repair Work Done J Type of Pump H.P. _ State Work Done t- <br /> Well Destruction )Q Well Diamet'r Sealing Material (top�50f) <br /> !! Depth __ { �� Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I-REPAIR/ADDITION I I ,OESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other el <br /> Number of living units: Number of bedrooms . t 1 { <br /> n -j <br /> Character of soil to a depth of 3 foet_r-. . __ . --Water table depth <br /> SEPTIC TANK L I Type/Mfg Capacity. _ No. Compartments -- _ <br /> PKG. TREATMENT PI.T. O + y '"-"T Method of Disposal , <br /> Distance to nearest: Well. Foundation Property Line _ _ <br /> LEACHING LINE 0 No. & Le+gth of lines �_ + _ Total length/size-- <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation- Property Line _ <br /> I , <br /> SEEPAGE PITS_ I I lktpth -- _Sire Numer�~� <br /> SUMPS L'. Distance to nearest: Well_._ _ Foundation _ Property Line___ l + 15* <br /> DISPOSAL PONDS I I "}-.� '• /; <br /> Thereby certify tfiat 1 have prepared tfiis a'pplicafion and tha` tFre woik wiA�e done iF actor nee wiih Sawn Joaquin county or inancus, state laws, ant <br /> rules and regulations of the San Joaquin Local Health Dstrict. <br /> Horne owner or licensed agent's signature certdies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any perso 'n such manner as to;become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the fol in : "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 /> lion laws for a•"The appli t n t call for all:t�t <br /> Complete drawing on ev side. <br /> Signed X— _ Title: --� �� Date: . ;k <br /> OR�PART�MENT USE ONLY <br /> Application Accepted by Date_1 <br /> Pit or Grout Inspection by Dale Final Inspection by pate r _ r <br /> Additional Comments: Gf Cr <br /> I.; Stk 466 6781 i-) Lodi -3621 Li Manteca 823 7104 L 1 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE `� AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT-No. <br /> . EH 11f?D 3 24(REV. <br /> Eir `tr✓�}( r o°00� .505 ZR 2 f d <br /> �^r t <br />