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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZEILT ON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> EXPIRES I YEAR FROM DATE ISSUED <br /> PERMIT EX Zs . <br /> (Complete i ' Triplicate)' <br /> t and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construc <br /> made in compliance With San Joaquin County Ordinance No.549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> PM <br /> Job Address <br /> r ot siie le—,P"�L: <br /> J <br /> City <br /> YAe <br /> 110 <br /> (5 Phone <br /> Address, <br /> Owner's Name <br /> Phone <br /> Z-4-51-c-_!t AZ W.1 Phone <br /> WELL <br /> cense No <br /> Contracto REPLACEMENT NEW WELL 0 WEREPLACEMENTL3 ut:z,1 nUCTION 0 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR D OTHER 0 <br /> PUMP INSTALLATION El DISPOSAL FLD.— PROP. LINE <br /> DISTANCE To NEAREST: SEPTIC TANK SEWER LINES OTHER WELL <br /> PITS/SUMPS <br /> FOUNDATION A ICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM A 'A CONSTRUCTIPVISIPECIFIC4ilONS Dia of Well Casing <br /> 13 Industrial 0 Open Bottom E] Manteca pia. of Excavation Specifications <br /> of Casing <br /> 1:1 Domestic/Private E Gravel Pack 13 Tracy I Type of Grout <br /> E] Public El Other 0 Delta De of Grout Seal <br /> E Irrigation ---Approx. Depth ED E s t Surface al Installed by <br /> H.P. State Work Done <br /> Repair Work Done 0 Type of PUMP <br /> Well Destruction E3 Well DiameterI Sealing M:aterial atop 50') <br /> Depth Filler Material (Below-50f) if public sewer is <br /> ION DESTRUCTION 11 (No septic system permitted <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 RE, I <br /> available within 200 feet.) <br /> Commercial 'Other <br /> installation will serve: Residence_�c .. -4"A_, <br /> Number of bedrooms <br /> Number of living units: —A- depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity_Z_ZV—AL)—.,'�No. Compartments <br /> SEPTIC TANK Type/Mfg "Method'of Disposal <br /> r�'L2__jQ��.PropArtY <br /> PKG. TREATMENT PLT. n Line <br /> h <br /> Compartments A 'CUL'u"t vv LLL <br /> R B-EM CONSTRUCT' SPECIFIC <br /> L Excavation f <br /> cav <br /> Manteca <br /> Di,_ of E-cavaton Specifications <br /> offi, <br /> M <br /> Tr'.y of Casing <br /> T <br /> [3 Delta De of a rout Seal Type <br /> ED Ea t Surface 'I Installed <br /> by <br /> as <br /> State W" <br /> k Do,, <br /> Sal <br /> �71 <br /> Distance to nearest: Well_66_0�� Found,tid <br /> Total length/size <br /> LEACHING LINE No. & Length of lines, <br /> qV Line <br /> 5 Distance to nearest: 1 'Well Foundation Property <br /> FILTER BED <br /> _--Number <br /> Size <br /> SEEPAGE PITS -,K Depth i <br /> Property Line <br /> SUMPS El Distance to nearest: Well F undation <br /> DISPOSAL PONDS ❑ <br /> and that the work will be done in accordance with San i'Joaquin-county ordinances, state laws, and <br /> I hereby certify that I have prepared this application i i <br /> ns of the San Joaquin Local 1-14th-District. r issued, I shall re <br /> employ <br /> and regulations d agent's signature,Gertifies-thb following.. certify that'in,the performance of the ork actor <br /> hihjsignatureHome owner or license as to become�subfect to workman's�ompensatio'n laws of CafifON6i�i"' Cointr . 's hiring or sub-contractinE <br /> employ any person in such manner performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> certifies the following: "I certify that in the perform <br /> tion laws of California." 'd <br /> The applicant g o <br /> must call for all inspections. complete drawinn reverse side." Date: <br /> Signed Title: <br /> DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by L5 <br /> i, Date <br /> ate Final Inspection by /,3 i(_) _� Z� <br /> D Vo <br /> Pit or Grout Inspection by <br /> 7- /S <br /> Additional Comments: - TkA6� UA� J <br /> 0 Stk 466-6781 0 Lodi 369-3621 C1 Manteca 823-7104 71 Tracy 835- 2009, Stk., CA 95201 <br /> it <br /> Applicant- Return all copies to: Envirohmental Health Perm' /Services 1601 E. Hazelton Ave., P.O. Box <br /> AMOUNT REMITTED CK RECEIVED BY DATE. PER IT;q <br /> FEE AMOUNT DUE. -CASH <br /> INFO <br /> EK 1324 IREV.1 13 6) <br /> EH 14-25 <br />