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APPLICATION.FOR PERMIT
<br /> ,,. SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZELTON AVE STOCKTON, CA
<br /> Teiep me =1 41664M
<br /> PERMIT EXPIRES 1`YEAR FROM DATE.ISSUED
<br /> .
<br /> -(Complete-In. Triplicate);=I h. ,� i>w 'bn ': �t►i13us� .
<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 aprplication'is i
<br /> made in compliance with San Joaquin County Ordinance No.$49 for sewage or No. 1862 for welllpump andithk Rules and Regulations of the San Joaquin i
<br /> :.cool!Health District'.
<br /> Job Addres 1.._._.._..___. _ ,t.��Y....... ... _.'`.. ..__. City Lot Size _. PM. ._.....
<br /> __
<br /> Owner's Name ~ " ?i: .l � a Adite s Y_ .__8-'4b
<br /> - Phone
<br /> . _
<br /> Contractor_-A,2, A,"& ��`,�, Address� L�j,Z G�,� .._. License N`144� _Phar e
<br /> TYPE OF WELL/PUMP: ;NEW WELL.-O WELL REPLACEMENT i.:.i DESTRUCTION
<br /> PUMP INSTALLATION 0 SYSTEM REPAIR L OTHER D
<br /> DISTANCE TO NEAREST: SEPTIC TANK ___.._......._,.._........_...... SEWER LINES' DISPOSAL FLD. PROP. LINE i
<br /> FOUNDATION AGRICULTURE WELL &f4kR WELL—..___
<br /> _ PITS/SUMPS _
<br /> INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> O Industrial D Open Bottom Ci Manteca Dia. of Well Excavation__.. Dia. of Well Casing
<br /> 0 DomesticlPrvate 0 Gravell'''aclt--z 2�L,Tracy- ��, Type of Casing Specifications
<br /> ;. Public :2 Other C7 Delia L Depth of Grout Seel Type of Grout --
<br /> =1 Irrigation _..._Approx, Depth' N 'Ee3iern try
<br /> t'
<br /> _ Surface Seal Installed - `
<br /> �. Repair Work Done I:: Type of Pump ,,. .._. � �H':P.' _.__......... State Wotk Done_
<br /> Well Destruction [ Well Diameter. Sealing Material {to 50'j _
<br /> ----y«,-DeptS- ler-Material-t8elow•Fri)'-?.•.-„_......__,_�..._:. �...�...._...,..,;..
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L DESTRUCTION C,iNo septic system permitted if'public sewer
<br /> l;s
<br /> t -. ,• y »r i . r 7` '`available within 2W feet 1-
<br /> Installation will serve: Residence Coma ldralal Otber _ 4 .W. .....
<br /> ..
<br /> i+lu'rnbar o'Wing units: l Number of bedrooms
<br /> Character of soil to a depth?f 3„feet: __ �.._.Watet tabte'dpt4Ft jY _ _
<br /> SEPTIC TANK Type7Mfg © '��_ 3 Pa _
<br /> _._.....7, Capacity—,� w.No.Com rtments`>
<br /> PKG. TREATMENT Method of Disposal i
<br /> ..._.......
<br /> j Distance to n&er& J Well �t, ,Foundation,ijA "}'i rty Line
<br /> I LEACHING LiNE >✓t No: &—LenLgth_;of fines __�1� X1''b� . Total k+i'igttrisize.
<br /> I FILTER BED lv"Distanceito nearest: - Wen ,,� Foundation A3?!!_,Property Line_:S
<br /> _...
<br /> SEEPAGE PITS ` 0 DWM Size ___. Number
<br /> SUMPS t , Property Line U
<br /> i t
<br /> DISPOSAL PONDS ;. 1W�f
<br /> I hereby certify thatl=prepared this application and that the 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 /> Home owner or licansed agent's signature certifies the"following."I certify that in the performance of the work for which this"petrrtit is•issued, I shall not
<br /> employ any person in such rr>anner as tvbec"subject to workman's compensation laws of California,"'Contractor's hiring or sub-contracting signature
<br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,i shall employ perspns subje to woriirnan's compensa-
<br /> I tiara laws of Californw."j A $
<br /> Thea applicant must call;for d!i r red in ! tions. Com c t
<br /> pp Complete drawing on reverse side z
<br /> � Signed X_
<br /> i FO EPARTMENT USE ONLY
<br /> Application Accepted by3 — _ _ _ w........ .... .....
<br /> Data
<br /> A m a
<br /> j Pit or Grout Inspection by j
<br /> t # _. Date _-.. Final Inspection by Data . qty
<br /> i L
<br /> t Additional Comments:
<br /> Stk 466-6781 G Lodi 369-3621 _i Manteca 823-7104 L] Tracy 835-6385 � t
<br /> Applicant - Return all copies to: Environmental Health Pdrmt/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 9=1
<br /> fEEINFO AMOCK 4
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