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p <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i Telephone(209)466-6781 <br /> •3 U PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I <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. �E` �f6•Tn f <br /> Job Address _ _. atm YB(AeC. 'd Lot Site t- PM - - <br /> Owner's Name Address 4&V C' Phone / r <br /> 69 v C,y4tracto \ 1 License <br /> ,�. TYPE OF WELUPUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION 0 <br /> PUMP INSTALLATION-0 r� �.. SYSTEM REPAIR O OTHER ❑ d <br /> -DISTANCE TO NEAREST: SEPTIC.TANK`�'�' �- SEWER-LINES DISPOSAL FUD. PROP.LINE <br /> No o FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS= <br /> INTENDED USE Wk OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0.6ldustrisl 0 Open Bottom 0 Manteca Dia.of Well Excavation Dia.of Well Casing <br /> n <br /> ' 0_Dprriest �/hi�i-v[a-te!�- ❑Gravel Pack _ ❑Tracy Type of Casing_ Specifications <br /> tOblic f J Other ;ii,' r0'OeltaDepth of Grout Seal Type of Grout — <br /> tf (a Irrigation � prox.Depth Oy Esstem Surface Seal Installed <br /> Repair Vy�, 7.Oone�fll Type of Pump •1- H.P. State Work Doiii <br /> Well DBsttt aion• ❑ Well;Diameter. Y; Soling Material(top 50') _ Iv <br /> t <br /> Depth - --Filler Material-IBebw-501--, YPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION O DESTRUCTION❑ (No septic system permitted 8 public sewer is UN <br /> .i_ i ; available within 200 feet.) Q <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units:� Number of bedrooms I <br /> ' Charecter of soil to a dap h of 3 feet: - Water table depth�Qtj <br /> SEPTIC TANK li Type/Mfg _.,��_.-d'QS�_�—f�_Capadty Q _ No.Compartments - 1 <br /> PK&TREATMENT PLT.❑ d r Method of DispssaI <br /> 1 ' <br /> Distance to nearest: Wel•I�__= Foundation 142 Property Line _S� v ,. <br /> LEACHING LINE '®/No:8 Length of lines_; �� Total length/size - <br /> FILTER BED fl Distance to neehst:rr'Well J!,,Zy- Foundationi. '' Property Line /•n <br /> SEEPAGE PITSr YY Depth Size ��� Number <br /> i <br /> SUMPi Cl D•Istarlcs to nearest: Well — Foundation �f n - Property Line <br /> DISPOSAL PONDS O <br /> -� - 1 heisby certify that I have prepared this application and that th work will be done in accordance.with San Joaquin county ordinances,state laws,and ' <br /> rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or licensed agelt'e signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall not __ - <br /> employ any person in such mariner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractirg 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- ,y <br /> tion lavini California." <br /> The applicant m for r'si inspections.Complete drawing on rave a side. <br /> t <br /> Signet)X / Title: Date: <br /> 1' F DEPARTMENT USE ONLY I _ <br /> Application Accepted by �r11 ���j..-- w�<•.0 iv✓'�r Date 1 Area_ ' <br /> s, <br /> i / S9 '7 <br /> n r Grout Inspection by Date� �Frol Inspection by Dat6 Q� / <br /> Additional Comments: <br /> ❑Stk. 466-678f f, :L'adi 3W3621 ❑Manteca 823-71 ❑Tracy 8358385 <br /> Applicant-Return all 'to:Environmerrtal Health Pertnk/Services iBDi E.Hazelton Ave.,P.O.Box 2009,Stk.,CA 95201 <br /> .,pig. <br /> FEE AMO0N"T DUE AMOUNT REMITTED CK a CASH RECEIVED 6Y DATE PERMIT NO. <br /> INFO �y <br /> .ER1a-alIli llrsa <br /> ex tax U'D O <br />