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APPLICATION FOR PERMIT Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091466-6781 <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.548 for sewage or No. 1862 for wee/pump and the Rules and Regulations of the Sar Joaquin <br /> Local Health District, <br /> Job Address A889 E, 80Th !7lcl• Cityr�r>r CA�r Lot Sue PM ' <br /> Owner's Name /���T CRN T?:'fl 1lr Addraa jr89 E '7 Th ow. Phone JfA _V-S 'y ' <br /> Contractor Address License No. .Phone ) <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION Q <br /> PUMP INSTALLATION D SYSTEM REPAIR D OTHER C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION•SPECIFICAIRONS'. <br /> D Industrial O Open 0ottetm ❑Manteca Dia.o1 Well Excavation Die.of Well Casing <br /> 0 Domestic/Private D Gravel Pack D Tracy Type of C*91ng,._. Spaciffcatigns <br /> I'1 Public f,1 Other f9 Delta Depth of Grout Seal _ Type of Grout _ t <br /> 1 I litigation Aptaok. Depth 1 I Eastern Surface Saar Insisted by <br /> Repair Wmk Done O Type of Pump ... H.P. - State Work Done <br /> Well Destruction ❑ Wed Orertater Sealing Material NOP 509 = <br /> Depth Filler Material(Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I R£PAIR/ADDITION A DESTRUCTION I I (No septic system Pcrmlued if public se is p, <br /> available within 200 feet.] py <br /> Installation will serve: Rasidance__ Commercial_ Other �f'erP C�e 1.11.T 1F ' <br /> Number of living units' � Number of bedrooms <br /> Character of soil to a depth of 3 feet: Xl�y AaA.M Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments <br /> PKG. TREATMENT PLT.❑ —Method of Disposal <br /> Distance to nearest: Well FotRWation Property Line <br /> r <br /> LEACHING LINE 13 No,6 Length of lines —I '^ 6 Q ',Y 34X'8` Total length/site 6 4' <br /> FILTER REO ❑ Distance to nearest: Well Foundartiun. Property Lina <br /> or <br /> ' SEEPAGE PITS 11 Depth __ Site Number <br /> SUMPS L9 Distance to nearest: Well Fi undaiiori„'' Ptopetty line <br /> DISPOSAL PONDS G " <br /> 1 hereby certify that I neva prepared this application and that the work will be done In accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulation;of the San Joayum Local Health DiNtict. <br /> Homs owner or ilconse l agent's signature canines the following! "I certify that in the performance of the work for which this plarmt is issued, I shall not <br /> employ any person in such manner as to became subject to werkman's compensation laws of California."Contractor's hukig or subcontracting signalure <br /> certifies the foaowktg: ­1 certify that in Into perlamanco of the work to which this permit is issued.I shax employ persons wbfecl to wakiman's compatsa• <br /> tlon laws of Califolnia." <br /> The applicant mu coil la all r pectidns. Complete draw t <br /> oquerd ins pie drawing on reverse side. <br /> Signed x tn7_0_;� <br /> tiIla: _... . 1 Detc Lx`/6 —fH) DEPARTMENTUSEONApplicationAccepted by Date - Arai <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> O Slit 466 6791 ❑Lod 369,3621 D Manteca 823.7104 ❑ Tracy 835•6385 <br /> Applicant- Return all copies to:Enviroramentod Health ParenitlSemicea 1601 E_ Hetelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> _ FEE AMDUNT DUE _ AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> 9NE0 <br /> ..Ere ta-H nttY.nasi - D <br /> Ent«e r° <br /> i - <br />