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_J <br /> APPLICATION FOR PERMIT <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT z E5 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA z <br /> A Telephone (209) 466-6781 <br /> -- .PERMIT EXPIRES TYEAR 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. 1862 for.well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address _. <br /> � e 4 , ' City�r` -i Lot Size PM <br /> r � <br /> Owner's Name ress 0 -4 3 15! _ Phone <br /> ' essrPhone <br /> 7 S <br /> I TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a r DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well.Excavation Dia. of Well Casing {1iv1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy i'ype of Casing Specifications <br /> M Public '"' .M:,'Other" '" :,_. Cl Delta Depth of Grout Seal Type of Grout <br /> _..Approx. Depth [ I Eastern Surface Seal Installed by <br /> I I Irrigation r <br /> Repair Work Done f ❑ Type of Pump H.P. State Work Done _ r <br /> Well Destruction ❑ Well Diameter Sealing Mate i�"ftop 501 <br /> Depth Filler MateriallI-Beiow 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 4 Installation will serve:^ Residence_ Commercial_ Other € (� <br /> i Number of living units: Number-of-bedrooms"'r"� ­ <br /> t Character of soil to a depth of 3 feet: -- _ Water table depth <br /> SEPTIC TANK t ❑ Type/Mfg Capacity �No. Compartments <br /> r PKG. TREATMENT}PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ .No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> + DISPOSAL PONDS ❑ <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, and <br /> rules and regulations of the San Joaquin Local Health District. i <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 shalt not <br /> employ any person in such manner as to become 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> + The applican must call for all pections. Complete drawin n reversee side. <br /> Signed K A. Date: +� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout'Inspectiontw ' zte T Final Inspection b _ Date <br /> l 13 <br /> Additional Comments f - <br /> : ❑ Stk 466-6781 G-'nodi'o�W-o-M r ❑ Mafnecs- 823-7104 ❑ Tracy 835- �Q <br /> jApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelto` ve., P.0 Box 2(1)9, Stk., CAQ5201 / "�^t <br /> ' INFO AMOUNT DUE AMOUNT REMITTED �K 1 RECEIVED BY DATE ��PPE/R7MIT'NO. <br /> + 'R <br /> EH 13-24 IREV.r i n s 1 _, t- _/�V !tQ <br /> EH 14-28 �' <br /> k <br />