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r <br /> �V. <br /> y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> }t' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROi;1 DATE ISSUED <br /> (Complete in Triplicate) <br /> rf appilication <br /> Application is hereby made to the San Joaquin Local Health District for a permit to corstruct and/or install the work(weir+dMcribed•� 1e <br /> made in compkance with San Joaqs San Joaquin <br /> uin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulttlorr <br /> i' Local Health District. <br /> Job Address <br /> STi;A--C 9 v L BJ City��rLe N Lot SizePM <br /> i � L m U rh Address <br /> Owner's Name .{ Ri C b ss SNi`1lf Phone <br /> yA <br /> l Contracts <br /> ON s��' Addresses .'Z 6T L✓e �+ /i v� License No. ✓� Phone <br /> TYPE OF WALL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O \ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ <br /> _.. <br /> DISTANCE TIO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of W04 C,� <br /> ( ❑ industrial ❑ Open Bottom C Manteca Dia.of Well Excavation SP�ficatary <br /> T of Casin, <br /> ❑ Domestic/Private C Gravel Pack ❑Tracy Type q Type of Grout <br /> ❑ Public - --— C Other ❑ Delta Depth of Grout Seal <br /> ' C7 Irrigation ---Approx. Depth' ❑ Eastern Surface Seal Installed by <br /> �^ T of PUMP H.P._ State Work Done <br /> Repair Work Done ❑ <br /> Type - - <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material(top 50') <br /> Depth Filler Material(Below 50') <br /> ed it putliC sewer is <br /> `. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONx DIll ESTRUCTION ❑ available within(No septic 2t70 feet) <br /> 4 .. <br /> Installation will serve: Residence� Commercial_ Other <br /> Number of bedrooms <br /> r Number of living units:_� O M _Water table depth ' <br /> Character of soil to a depth of 3 feet: Capacity No. Compartrnents <br /> SEPTIC TANK LC- Type/Mfg MethodtD" l <br /> PKG. TREATMENT PLT.❑ Qp' Foundation �S Property Line <br /> Distance to nearest: Well�— <br /> �', Total length/size <br /> LEACHING LINE ❑ No.&Length of lines Property Line <br /> dation <br /> FILTER BED C1Distance to nearest: Well <br /> Foun <br /> Size q Number <br /> + SEEPAGE PITS a Depth a� Property line �Qe <br /> 1 ❑ Distance to nearest; Well <br /> /IO' _ Foundation <br /> SUMPS <br /> ordinance3l,stillitill laws,and <br /> DISPOSAL PONDS C in <br /> r(�c I hereby certify that I have <br /> the SB Prepared <br /> this aLooalRtior'and Health District.the work will be don h® accordancewith <br /> o1 the work 1w Joaquin <br /> which th s Pentyl leaned, s11aM not <br /> rules and regulations o <br /> Home owner or licensed agent's signature certifies the following: "I certify that in pe <br /> "1 certify that in the performance of the work for which this permit is issued..)shall employ persons subject to wnrkmari s eorttpen+a' <br /> employ any person in such manner as to ber.ome subject to workman's compensation laws of California."Contractor's hiring or sub-conttacun9 sr�ature <br /> certifies the following: <br /> tion laws of California." <br /> The applicant must all for all required insFections. Complete drawing on reverse side. Date: <br /> Title: <br /> Signed X <br /> FO DEPARTMENT USE ONLY ^% <br /> � i Date Area //(� <br /> Applicstion Accepted by Data <br /> Date Final Inspection by <br /> Pit or Grout Inspection by <br /> } Addit"O";Comments:: -7104 Manteca 823-7104 ❑Tracy 835-63B5C Stk 4666781 all <br /> 36&3621 <br /> Applicant- Return all copies to: Environmental Health Permit/Servi�a 1601 E. Hazehon Ave., P.O. Box 2009, Stk•, CA 95201 <br /> CK+ RECEIVED BY <br /> FDATE PERMIT•N0. <br /> EE AMOUNT DUE .+MOUNT REMITTED CASH <br /> INFO <br /> EM 13-241REH.1.'N5i r <br /> EH 1 <br /> &3a <br />