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APPLICATION F6R.PERMIT <br /> SAN JOAQUINI(;CAL �iEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4156-6091— <br /> PERMIT EXPIREii ].YEAR FROM DATE ISSUED <br /> (Complete in,Triplicate) to <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiri 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.. (I t' <br /> tot 1E <br /> el <br /> PM.. <br /> Job Address ..1101 T�Z C-L,- city, I Lot Size <br /> Owner's Name Address _IIAA � e_ Phone <br /> License No. SAD Phone C16 g 2.,V <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT 0 r DESTRUCTION El <br /> 7� <br /> iT <br /> PUMP INSTALLATION-0—_ SYWREPAIR. OTHER-0 <br /> 7��� <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES 'bf!�por�,kC,-FL'6 -PRdP.-LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial El Open Bottom 0 Manteca Dia. of Well Excavation a Dia. of Well Casing <br /> KDomestict Private El Gravel Pack C1 Tracy Type of Casing sSpecifications <br /> 1 <br /> El Public 17 Other El Delta Depth of Grout Seal ­4Type of Grout <br /> [I Irrigation ---Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done V Type of Pump H.P. State Work'Mone A10/7LI f' 40 <br /> Well Destruction El Well Diameter Sealing Material (top 501 ,, <br /> Depth Filler Material (Below 50'1 _7 67 <br /> TYPE OF SEPTIC WORK.: NEW INSTALLATION D REPAIR/ADDITION L DESTRUCTION E (No geVtic system permitted if public sewer is <br /> availabld within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units:— Number of bedrooms <br /> Character of soil to a depth of 3 feet: t. Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity �'No. Compartments <br /> PKG. TREATMENT PLT. 11 "Method of Disposal <br /> Distance iio!Leg:est: well Foundation Property Line <br /> LEACHING LINE 0' No. & Length of lines Total len. /size <br /> FILTER BED E. Distance t6-nearest: Well P Foundation 0 <br /> party Line <br /> SEEPAGE PITS El Depth -Size Number <br /> Well T-""F6_un6ti6n___f p <br /> SUMPS 'D Distance to nearest: Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District <br /> A <br /> Home owner or licensed agent's signature certifies the lo'llowin`g: I ce4othat-in thd performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's-compensation lawi of California-!"Contractor's hiring or sub-contracting signature <br /> certifies the following:"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 /> tion laws of California." F" <br /> The applic, st call for all M 'red ins g ions. Complet.e-drawing,on reverse side. <br /> "k <br /> T' <br /> Signed T' Date: <br /> I L <br /> OR DEPARTME T USE ONLY <br /> Date Accepted by Datff Area <br /> Z <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-3621 11 Manteca 823-7104 17 Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box M, Stk., CA 95201 <br /> CK* <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO CASH DATE.,— PERMIT`NO- <br /> +EH 1321(REV.10/831CIO <br /> EH W25 C5 <br />