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' APPLICATION,FOR PERMIT <br /> SAN JOAQUIN;LOCALHEALTH DISTRICT <br /> i 1601 E. HAZE TON AVE., STOCKTON, CA <br /> 'Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to ;,.(Complete in Triplicate) 10 <br /> the San Joaquin Local Health District for a permit to construct and/or install the u <br /> made H alth lance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and <br /> Local Health District. work herein described. This application is { <br /> Regulations of the-San Joaquin <br /> Job Address. r <br /> City...1 ,Lvt Size.. <br /> Owner's Name ' `'•P,M <br /> Address �l Phone 11� <br /> Contractof r <br /> TYPE OF WELL/PUMP: Address II / (/ (� e� �/ <br /> NEW WELL ❑ License No.�"+�l Phane�7 <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR ❑ OTHER C11 <br /> SEWER LINES, DISPOSAL FLD. <br /> E FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE TYPE OF WELL p OTHER WELL PITS/SUMPS <br /> ❑ Industrial R08LEM AREA CONSTRUCTION SPECIFICATIONS s <br /> ❑ Open Bottom EJ Manteca t— e~ - Dia. of Well Excavation r i f <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ' ❑ Public ❑ Tracy �TYPe of Casing <br /> ❑ Other"'- .. ❑ DeltaSpecifications . <br /> I <br /> EJ Irrigation Pepth of Grout Seal <br /> Approx. Depth -❑ Eastern. Surface Seal Installed by Type of Grout <br /> Repair Work Done ❑ Type of Pump <br /> H.P. ;.. <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 50') a <br /> Depth M.—M <br /> TYF SEaterial (Belo 501) ` <br /> PE OPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION E r N <br /> DESTRUCTION ❑ (No septic system,permitted if public sewer is <br /> Installation will serve: Residence! J— '"'-"'"'"'available within 200 feet.) <br /> Commercial_ Other <br /> s Number of living units: Number of bedrooms <br /> Character of soil to adof 3 feet: <br /> ept d <br /> SEPTIC TANK Type/Mfg ' Water table depth ; <br /> PKG. TREATMENT PLT. ❑ < Capacity No. Compartments <br /> 4 ' 444��� <br /> Distance to"nearest: WellMethod o Dispo al <br /> Foundation Property Line <br /> LEACHING LINE ❑`` No. & Length of lines i 4 <br /> a <br /> FILTER BED ❑ Distance to nearest: :.W Total length/size" <br /> url"atio Property Line u <br /> SEEPAGE PITS ❑ Depth <br /> S, <br /> SUMPS ❑ Distance to nearest: <br /> DISPOSAL PONDS ❑ ell FdLndation .Property Line <br /> ` i <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance <br /> rules and regulations of the San Joaquin Local Health District. s, state laws, and, <br /> Home owner or licensed agent's signature certifies the following: A <br /> employ any person in such manner as to become subject to workman's compensation laws of Califonce rnia."Contractor'se work for lhiringch 'opsub-contracting lsignalnot <br /> turre <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica t must call fo all r uired in pections. Complete drawing on reverse side. j <br /> Signed <br /> Title: <br /> Date: <br /> �FOO ]I=PARTM1AEN7 USE ONLY <br /> Application'Accepted by1`2��r <br /> Date F �s A ; <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: JL <br /> ❑ Stk 466-6781 ❑ nodi 369-3621 <br /> El Manteca 823-7104 <br /> ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT:NO. <br />+ EH 73-24(REV.i/e 5) <br /> EH 14-26 �� d _ Q�L r <br /> c, -. <br /> ` � 15� <br />