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APPLICATION FOR PERMIT <br /> I� SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 7 F O <br /> 1601 E. HAZELTN AVE., STOCKTON, CA <br /> Telephone (209) 466"6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` (Complete in Triplicate) application's <br /> and the Rules and Regulations of the San Joaquin <br /> Application is heleby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This app <br /> made In compliance with San Jd7aquin County Ordinance No.549 for sewage or No:1862 for well/pump <br /> Local Health District. <br /> VIP qcyes <br /> /9eZ/ id fJscd/,O <br /> 13e k City LoT.9 �^^" t♦� Lot Size. PM <br /> job Address Phone <br /> Address <br /> H Owner's Name �• ����� Phone SNP. License No._-�--- „/.. <br /> l {.� Adtlress DESTRUCTION ❑ <br /> 4 ConEWEL ❑ <br /> tractor WELL REPLACEMENT ❑ OTHER D �' l <br /> NW L <br /> TYPE OF_. WELL/ SYSTEM REPAIR O pgOp, LINE <br /> !1 t PUMP INSTALLATION O DISPOSAL FLD. <br /> SEWER LINES �� OTHER WELL PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL <br /> .FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> v TYPE OF WELL PROBLEM AREA Dla, of Well Ceasing J <br /> f INTENDED OUSE c – Dia. of Wall Excavation�— Specifications -,� <br /> ❑ Open Bottom 0 Manteca <br /> ❑ Industri Tracy p Type of Casing <br /> O Domestic/Private d Gravel Pack Type OI Grout. - C' <br /> Ll Other ❑ Delta Depth of Grout Sea' �� , <br /> 60 11 Public ��tt Surface Seal Installed by <br /> 1 Irrigation 9�APWox. Depth 1 I Eastern State Work Done-- <br /> H.P. <br /> Repair Work Done 13 Type of Pump i' <br /> Well Diameter Sealing Material (top 50'1 f , <br /> Well Destruction Filler Material (Below 50') rT1 <br /> Depth_ `11 <br /> 1 available within 200 feat.) <br /> TYPE OF SEPTIC WORK: I9+�NEW INSTALLATION REPAIR/ADDITION I I DEST C'rION.I 1 (No able system permitted if public sewer 1s <br /> Installation will serve: Residence L. Commercial_ Other / 1 <br /> V ( l Number of bedrooms /00 <br /> Number of living units: _ i Water table depth <br /> Character of soil to a depth of 3 feeb C �F / Oapacity, ��� No. Compartments ps <br /> ;-SEPTIC TANK O1 Type/Mfg Method of Disposal <br /> ` PKG.TREATMENT PLT. `6,!♦l propeLine rty So♦ <br /> I -1130 ♦ Foundation <br /> Dieeme to nearest: i ell–/— ,r <br /> i <br /> 3 - (e/O ♦ Total length/siies� �9 <br /> + LEACHING LINE I? No. & Length of lines .._ r �♦ - I <br /> 'FILTER BED A Distance to nearest: We11:� /OD Foundation 61r' Property Line ST <br /> - I <br /> /SEEPAGE PITS Depth A 5♦ Size f 96 re ZYVA, II —� Number <br /> ' I AO' FO.1dw..n s`�♦ Property Line-0 <br /> ` LIMPS L•l Distance to nearese Well_�—. i z <br /> DISPOSAL PONDS b ' <br /> 1 hereby certify that l have prepared this application and that the work will be dori'e in accordance with San Joaquin county ordinances, state laws, and C <br /> rules and regulations of the San Joaquin'Local Health Dibtrict. I shall not <br /> Home owner Or licensed agent's signature certifies the following: "I certify that in[he performance of the work for which this permit is issued, <br /> employ any person in such manner as to become subject to workman's compensation laws 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 /> 1.' tion laws of California." 1 r `• <br /> ,1 The applicant mus[ all for all required inspections. Complete drawing on reverse side. <br /> I. L ) i Title: Date: <br /> 9- r- 90 <br /> I Signed r• I _ ' <br /> y FOR DEPARTMENT USE ONLY 7 1 <br /> ✓ )r Arae " <br /> � Application Accepted by Date- <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Additional Comments: B <br /> O Stk 4664781 0 Lodi 369-3621 ❑ Manteca. 913-7104 ❑ 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 /> d <br /> FEE AMOUNT DUE MOUNT REMITTED C HRECEIVED BV DATE PERMIT NO. <br /> INFO <br /> r EH 13NIREV ,,.z1 ( , 1435 <br /> EH 14-M <br /> 0 <br />