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APPLICATION FOR PERMIT <br /> 669 SAN JOAQUIN LOCAL'HEALTH DISTRICT P <br /> 1601 E. HAZELTON AVE., STOCKTON, CA FILE � <br /> Telephone (209) 466-6781 <br /> e PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> - .' �3,• (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 appooatim is <br /> made in compliance with San Joaquin County Ordinarioe No.649 for sewage or No. 1882 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local.Health District:.3nw „ <br /> Job Address Z-: G77�,�,:1� <br /> C• <br /> . ny, Lot Sime <br /> carer's Name Address 1 PCC-7-44 ,eD <br /> Phone 3 -� `s <br /> Contractaren ,okailiwI6 6Y- <br /> fM91 AddresscFcr. ,e License No. =T-2-0�6/Phone 33 -a 99 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTX DESTRUCTION <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Q _ SEWER LINES f DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El IndustrialJ9rOpen Bottom ❑ Manteca Dia. of Weil Excavation o"I- S Dia. of Well Casing <br /> ArDamesbc/Private Cl Gravel Pack ❑Tracy Type of Casing Rte'/- ez9,,crz­L Specifications �NIa <br /> CI Public ❑ Oilier ❑ pelta Depen of Grout Seal <br /> Type of Grout <br /> C3 irrigationpprox peuth ❑ Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction A- Weil Diammt rf Sealing Material (top f&) .Si( lQ 0117- <br /> Depth /o; Filler Material I8elow W) •s�4/V!J' <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTR <br /> r UCTION Elpti <br /> (tic sec system permitted if public sewer is <br /> with ' <br /> Installation will serve: Residence Commercial— Other available in 2W feet.) <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet:3' Water table depth <br /> SEPTIC TANK D Type/Mfg: CaPBcitY No. Compartments <br /> r PKG. TREATMENT PLT.❑ ° t r <br /> Method of Disposal <br /> Distance to nearest: ` Well Foundation property Line <br /> •,.'� <br /> LEACHING LINE ❑ No. A Length of lines Total length/slze <br /> FILTER HED L7 Distance to nearest: Well Foundation Property Line <br /> F 4. <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS :`' ElDistance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ { <br /> I hereby certjfy'that I have prepared this application and that the work will be done in acoordimce with San Joaquin county ordinances, state kews,and <br /> rules and regulations of the San Joaquin`Local Health District. <br /> Home owner or licensed agerrt's signature certifies the following: "1 certify that in the parfomtence of the work for which this per is isstied, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Car Contractors hiring or sub caneracteng Signature <br /> certifies the following:"I certify that In the ante of the work for which this permit is issued.1 shall employ persons subject to workman's co <br /> don lavra if mis." mpensa <br /> Thea ` _ m at r all r re i ctions. Complete drawing on reverse side. <br /> signed <br /> rift. / i<CJI� Date: —� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` Date --2 — <br /> Area <br /> Pit or Grout Inspection by // Date Final Inspection by pate <br /> Additional Comments: .fid <br /> CI Stk 466-Ml O Lodi 30,M1 ❑ Manteca 82.3404 CI Tracy 836.8385 <br /> Applicant- Return all copies to: Environmental Heakh Permit/Services 1601 E- Hazelton Ave., P.O. Boot 2009, Stk.r CA 9=1 <br /> NTLJ- <br /> 0414-29 <br /> MOUNT DUE i AMOUNT REM TTED RECEMO BY DATE PERMIT NO. <br /> CASH <br /> +EN ty24 IfeEv.i/as; =y <br />