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ti APPLICATION FOR PERMIT r.r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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. 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. <br /> Job Address 2 3 L O City.T��^ Lot Size PM <br /> Owner's ame 7=_" ,r3 Nva-e�z-4 Address 23"7 S 4. <5 Ko� Phone <br /> c� <br /> Contra Fe Or" Address p6.1 N 57S CA- eeTGvf License No. I-C Phone Z-62 <br /> TYPE ELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION �ib/!z�dy <br /> PgMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTA TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �i R PITS/SUMPS 9 <br /> INT D.USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C <br /> El Indu tial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ /Private 0 Gtavel racy Type of Casing SpehIfications <br /> ' tai 1 a <,.q L.ate L <br /> f7 '�� ❑ Offer � " Grout Seal Type dK Grout Z <br /> I I Irrigation �pprgx. Depth I I Eastern ._Surface Seal Installed - \ <br /> Re air ork Done MCJ T s p <br /> p Type bf Pum H.P. Slate Work/Done _ <br /> Well nation ri Well C�ameter ,Z ieal A'�Sealing Material (top 50'1 <br /> Depth' Z8 Filler Material (Below 50'1 <br /> TYPE F SEPTIC WORK: NEW NSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Nosepti stem permitted if public sewer is <br /> available within 200 feet.) <br /> l; <br /> Installation will serve: Residench_ Commercial_ Other Q <br /> Number of living units: Qumber of bedrooms N-N / < <br /> Character of soil to a depth of 3�et: Water table depth C <br /> r�kS,PPTI.0 TT -y O Type/ fg Capacity ,(No. Compartments I <br /> PKG. A E� PLT. ❑ /method of Disposal <br /> Dist to nearest: Well Foundation M Line <br /> f <br /> LEACHING LINE ElNo. & L ngth of lines Total length/size _ <br /> FILTER BED ❑ Distant to nearest: Well F ndation Property Line <br /> SEEPAGE PITS I I Depth — <br /> Size Number <br /> SUMPS 0 Distance dearest: Well Fou tion Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have preparedthispplication and t the work I be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin owl Health (strict. <br /> Home owner or licensed agent's signatur certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to a subject to wofkman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the rformaXoIth,, ork for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica call all quired in ctions. rawing on reverse side. <br /> Signed Title: YYYY C — Date: <br /> PART ET SE ONLY <br /> r <br /> Application Accepted by Date <br /> Pit or Grout Inspection by �f Date Final ectton by <br /> Additional Comments: T z PIT <br /> 0 Stk 466-6781 0 Lodi 369-3621_t_.i� antew-823- 9T1pf'"'pr Tracy 835- v <br /> ,,4, <br /> Applicant,. Retia vil nvlronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo1h2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 1124(REV.1/n m <br /> EH 14-29 • b�}S �� 11 ` <br />