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APPLICATION FOR PERMIT <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 Sen Joaquin Local Health District for a permit to construct andior instail the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.545 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> � ��r✓, t <br /> Job Address .. ` J"' !L■ City Lot Size Pfv1 _ l <br /> Owner_s,Name —�� Address <br /> Phone _�_ -- <br /> �.s 'Contracts _h AeU._. : 4AL.S:J Addrtss JC J LV License No.��V+� Phone e-? <br /> TYPE,OF WELL/PUMP: • NEW WELL n WELL REPLACEMENT 7 DESTRUCTION ID <br /> PUMP INSTALLATION 10 SYSTEM REPAIR n OTHER rJ <br /> DISTANCE TO'NEAREST: SEPTIC TANK ___"'SEWEI 'LINES .................- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ _... AGRICULTURE'WELL. OTHER WELL . PITSISUMPS � <br /> INTENDED USE ,,TYPE'OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial 0 Open 6ottorlaiJ Manteca Dia.of Well Excavation W'&a. of Wait,Casing <br /> 0 Domestic/Private Ca Gravel Pack D Tracy Type of Casing <br /> Specifications x` <br /> I-i Public t 1 other '— <br /> ``. n Delta Depth of Orou`i Sial __' Ty 'rif'Glout' _ <br /> I I irrigation .—.,Approx. Depth "-I I Eastern Surface Seat Installed by. <br /> Repair Work Done {l Type of Pump �� \ H.P. I State Work Done_ <br /> Well Destruction 1.3 Well Diameter Sealing MateriAj top 50') t _._.._.�_._.d•:_.__ <br /> Depth - ,Filter`fi laterial,48eiow 50'I' — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 rAO01TI0N I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 280 feet.l <br /> Installation will save: R ca C mmercial Other <br /> «_.. <br /> Number of tivu units: Number of bedrooms ?� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK &— ype/Mf Capacity No. Compartments t <br /> PKG. TREATMENT PLT. C} �,_ Method of Di �_ <br /> Distance to riearest: Wall Foundation_1 _ Property Lino_, 2 ,z__ <br /> 7 <br /> LEACHING LINE &--Nr&Length cif It.. � Total Iength/size <br /> FILTER BED Cl Distance to nearest: Well Foundation__ ! Property Lim ..... <br /> SEEPAGE PITS *-?`-�t#h Size__a.�r(��„� -_ .,_�..—y__M y�umber ..._�.__ ._•_ <br /> SUMPS0 Distance to nearest: Wet l'' r`.... foundation_L.. {., ___._. Property Line--- <br /> DISPOSAL PONDS CJ .�.. <br /> I hereby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin county ordinances,state laws, '"` <br /> rules and regulations of the Sart Joaquin Local Health DAuict. �. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> V person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> n ifies }lowin " cartify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman's compensa- <br /> tion Ia-$of r 1a." <br /> I mu it for I to drawing {averse si , <br /> Signa _ _ .. Title: _-_ —_ .— _ Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �` _ Date Area <br /> (J'UYor Grout Inspection by at. Final inspection t:y � Date •' <br /> Additional Comments: <br /> Stk---066-6781. —0 Lc6-,369.3621•...w...L,••'•Mateca^-,823=7104`.----O'Tracy'1835-6385, `" e""' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sore 3005, Stk., CA f952Mt <br /> EEE AMOUNT DUE AMOUNT REMITTED CK It RECEIVED By DATE PERMIT'NO. <br /> INFO CASH <br /> + EM1312401tv.»Aa) 7f).✓"! AZ2 <br /> >�r �/�y <br /> EM 14.26 ! v "R(J f3 Jt <br />