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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) 466-6* <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. TMs application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> VlJ , <br /> City Lot Size PM <br /> Job Address <br /> Owner's Name "C- r V 1Address 4 l Phone it <br /> Contra ctor_,x7i1� _ <br /> � 3a x <br /> �'�..�L�--- i�1.S ddress t�J - •License No. �_phone AQ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL'REPLACEMENT ❑ I DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE +TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ppp <br /> ❑FDomestic%Private_ ' ❑ Gravel Pick" "❑ Tracy­ -Type of Casing ` � T Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _T - f__:�4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done` ❑ Type of Pump H.P. -State Work Done <br /> Well Destruction >C7 Well Diameter Sealing Material (top 501 <br /> Depth _ Filter Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION AIR/ADDITION ❑ DESTRUCTION.❑ (No septic system permitted if public sewer is i <br /> i � � <br /> ce �. _ available within 200_ feet.) <br /> Installation will serve: Residen ��Gommercial her f <br /> Number of living-units:4— Number of b drooms {~ � <br /> t •. <br /> Character of soil-to a depth of 3 feet: - .. Water table depth <br /> SEPTIC TANK C1Type/Mfg C-n?►�_1 C IrF1 .. r Capacity-L%nnL No:Compartments <br /> PKG. TREATMENT PLT. ❑ ' ' 'ti �` ! <br /> L' } Method of Disposal <br /> Distance to nearest: Well T Foundation . property_Line <br /> LEACHING LINE �.�`& Length of lines ' <br /> . 9 � Totaf length/size- � � �+ <br /> FILTER BED 1-1Distance to nearest: Well1. Foundation s .Property Line l8� <br /> SEEPAGE PITS ❑ Depth Size 5.-'i Number i <br /> SUMPS ❑ Distance to nearest: Well: 1 !Foundation Property Line I <br /> DISPOSAL PONDS ❑ <br /> s! <br /> I hereby certify that I have prepared this application and that the work will be'done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the 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, ! shall not Y <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or subcontracting signature <br /> certifi he following: 'I c rtify that in the performance of the work for whi6F this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws o lifornia." # <br /> The applicant cal for al equ' d ins tion Co plete drawing on reverse sid . r <br /> Signed k Title: ate: <br /> r <br /> 1 FOR DEPARTMENT USE ONLY <br /> l } . <br /> Application Accepted by Date Area !r <br /> VWPit or Grout Inspe#ion by "^ Da- ­'—Final Inspection by Date 1 � i, <br /> 'Additional Comments: <br /> ❑ Stk 466 6781 JrL i 3621 ❑ Manteca 1 ❑ Tracy 835- <br /> El <br /> - Return,all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Bax 2009;Stk., CA 95201 <br /> It <br /> FEE s k d INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT'NO. if <br /> .+ EH 13-241REV: /.e 51 { (oos ,.1 <br /> EM 14.26 - v` <br /> , <br /> f <br />