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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 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. IB62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. � J { <br /> Job Address 7761 & +�` !-'�---- City. Lot Size PM <br /> Owner's Name /1 1V T- Addressd 1 � d-� hone <br /> Contfactor QO "4j,�` dress ��[/�if��/./tG 1 LicensefNo. hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEL'L REPLACEMENT ❑ DESTRUCTIbNJV <br /> PUMP INSTALLA - Y5 SI�EM f3 AIR <br /> .ION„❑ - - "- OTHER ❑ <br /> DISTANCE TO NEARESL-- <br /> T: SEPTIC TANK � SEWER LINES DISPOSAF_Lb! PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIOW-S'WJF �NS <br /> El industrial [I Open Bottom F1 Manteca Dia. of Well Excavation T`" Dia. of.Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of_Casing _ Specifications f <br /> I� Public n Other ( 0}Delta Depth of Grout Sea!_ l�� �_7_'fype ofI Grout !F <br /> I I Irrigation _..Approx. Depih I IlEastern - Surface Sal Installed by f <br /> Repair Work Done ❑ Type of Pump - -H.P----- + State Work Done _ <br /> Well Destruction Q Well Diameter Sealing Material (top 501 � �� • <br /> Depth l { Filler Material (Belo. 50i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR)ADdITION I 1 ESTR CTI N l 1 INo septic s ngperrpWao if public sewer is <br /> available w� tliitl°2,bD feet.I <br /> Installation will serve: Residence_ Commercial3the t 1 C <br /> Number of living units: Number of bedroJms. -- -- -�` _�•{�'t� <br /> Character of soil to a depth of 3 feet: t -_-- 'Water table depth <br /> SEPTIC TANK 0 Type/Mfg _ rapacity _. —_—No-Compartments <br /> PKG. TREATMENT PLT. ❑ { � i \t"� � ftAettiod of.Disposa <br /> l� <br /> Distance to nearest: e F1 its`af]_d151 """"'"""`"'"""'"`"Pf6V(3My Line' <br /> 1 <br /> i -� <br /> LEACHING LINE r L1 No. & Length of lid eS Total length/size <br /> FILTER BED a 1 1 ❑ Distance to larestt Well Foundation Property Line <br /> r' <br /> SEEPAGE PITS r. ' fl 7l Depth _ Size Number <br /> SUMPS `L1 Di <br /> SUMPS to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS U/ �� <br /> f hereby certify brat I'hav'4 repared this applicatf6� a d that th work will be done in a cSo kalhce�wi h�San_16ahuin county ordinances, state laws, and <br /> rules and rhi tions of the San Joaquin Local HealtA` District. <br /> Home owner oYlicen`sed algent's signature certifi&jth6 following "I certify that in the performance of the work for which this permit is issued, i shall not <br /> .employ any person, n s nor as to be ome subj ct toy'"mor man's compensation laws of'Cafrf Flria." Contractor's hiring or sub-contracting signature <br /> certifies the folio' nt5� I c y that in the perforrinance of thaw rk for which this permit is issued f shill�m��by persons subject to workman's compensa- <br /> tion laws of Califordi <br /> The applicant I requ" s tioRt. complete dawing on rover side. <br /> Signed X Title: ` Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date �Z-LV ��-J Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 1 <br /> —'—O-Stk 466°6781 (f)-VWF�--1631--(f)- antgea—S23--7104—L5T-r-at'"S35=638 <br /> Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> !FEENFO AMOUNT DUE AMOUN REMITTED CASH Y RECEIVED BY `• DATE PERMIT'ND. <br /> +.EH 13-24(REV.1/K 5) �7� OD <br /> EH 14-26 VVV O <br />