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I <br /> APPLICATION FOR PERMIT i <br /> A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s 1601 E. HAZELTON AVE., STOCKTON, CA l <br /> .a Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete 1n Triplicate) ' <br /> Application is hereby made to the Sar,.roaquin Local Health District for a permit to construct and/or install the work herein described.This appl(catlor..is <br /> s mado in compliance with San Joaquin County Ordinance No.549 for sewage or No.1B for well/pump and the Rtfles and Ragulations'of the San Joaquin. ' <br /> Local Health District. <br /> Job Address 8 Count Club Blvd C; , Stkn. Lot Size_82x194_= PIA <br /> Owner's Name Adin W Roda Address 1354 Canal Dr. , Stkn. Pfwne 463-5852 <br /> Contractor Owner AddressI <br /> Licerse No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> I <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR G OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 6 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> rr � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom ❑Manteca Dia.of Well Excavation Dia.of WO Casing <br /> ' ❑ Domestic/Private ❑ Gravel Pack <br /> C1 Tracy T of Cali <br /> Cl Public CC1 Delta Type ng---� Specifications <br /> ❑Other Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑'Eastem - Surface Seal Installed by <br /> Repair Wcrk Done ❑ Type of Pump H.P. State Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth Filler Material{Below 50') _ S# <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Li DESTRUCT N=1 INo <br /> septic sYsterrt pemtittEd M public sewer is <br /> - —available within 200 feet.I' <br /> tl Installation will serve: Residence— Commercial_ Other <br /> t. Number of Irving units: Number of bedrooms j <br /> Character of soil to a depth of 3 feet: Water table depth' ` <br /> SEPTIC TANK ❑ Type/Mfg- Capacity No.Compartments <br /> ' PKG. TREATMENT PLT.❑ Method of Dispotai V: <br /> i Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.8 Length of linea _ Total length/size <br /> FILTER BER ❑ Distance to nearest: Well Foundation Property Line <br /> E <br /> r* SEEPAGE PITS G Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wed_ Foundation_ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby Certify that I have prepared this application and that the work wili be done in accordan:e with Sart Joaquin county�,state lams,and ' <br /> rules and regulations of the San Joaquin Local Health District: <br /> Home owner of licensed agent's signature certifies the following:"I certify that in the performance of the work for which this pertnit is issued,4 shallnot <br /> employ any person in such manner as to become subject to workman's compensation laws of Celito.,a."Contractors hiring or pAbvonvactag algrtapme <br /> certifies the following:"I eertily that in the perfnrtttence of ft work for which this permit is issued,I shall ernpioy persons Subject to-orkrrwCa <br /> corroonew <br /> tion laws of Califomia." <br /> The applicant m I for�����rawiag on reverse aim. <br /> Signed Title: Qwngr1 <br /> 185 . <br /> FOR DEPARTMENT USE ONLY u <br /> '- Application AtcaptedA <br /> by <br /> las <br /> ' Pit of Graut Inspection by Date FinalIrwswction psn J 7 { <br /> rt l <br /> k <br /> rt. <br /> Ad-1;tion:,l Comments: ('X, l!l <br /> y7 5t:. 4i 6-ii781 12 Lodi 369.3521 ❑ Manumca M7-404 ❑Tracy 835.6385 <br /> 4�p5c3nt Return all copies to: Environmental Mesial Penrit/Servres 1601 E Haaeton R.ve., P.O. Box 7009,Silk.,CA952h <br /> r _ FEE <br /> AMOUNT DUE AMOUNT <br /> CASH <br /> DUNT REMITTED RECEIVED BY DATE pEfppt"11p, <br /> S. illi"r0 . <br /> [7 ` �o. �s� Com- �"/�IVFss 5.-b5 <br />