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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE4 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 Sari 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. rAP <br /> j City 4se.e-1 e i Lot Size PM <br /> Job Address " <br /> o { <br /> f} Phone 70 1 i <br /> Owner's Name ^��pTY>!� a tv h J Address <br /> i! ? 0*70" r _ Phone l-7_� �g <br /> Contractor's Name -' f License No. ��" <br /> �"TY.PE-OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION LlSYSTEM REPAIR 11OTHER El <br /> DISTANCE TO NEAREST: _SEPTIC TANK EW <br /> SER LINES„- <br /> ','*= ;x DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE 9 .- "TYPE OF WELLS. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom O Manteca Dia: of-Well Excavation Dia. of Weil Casing <br /> 3 ❑ Domestic I Private C1 Gravel Pack ❑ Tracy i Type,af.Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta I Depth of Grout Seal Type of Grout <br /> ! <br /> 11 _ <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump '� H.P. State Work Done <br /> ..t'o-_ t <br /> Well Destruction ❑ Well Diameter ;,,Sealing Material lop 50'1 4 µ <br /> Depth Filler Material'(Below 50'1 <br /> l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septilable wthinem fpermitted if public sewer is <br /> Installation will serve: Residence X Commercial_ Other <br /> r Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK � Type/Mfg *" Capacity / �® No. Compartments <br /> � <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t <br /> Distance to nearest: Well Foundation. Property Line <br /> � t _ iE <br /> LEACHING LINE ❑ No. & Length of lines Total len <br /> _ .1 d 1 gthlsize 00 <br /> FILTER BED ❑ Distance to nearest: Well Foundation: <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size X { Number f <br /> SUMPS N' Distance to nearest:'- Well Foundation 0 ! Property Line <br /> DISPOSAL PONDS ❑ R O r {A Gs C.^l" <br /> 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. <br /> 1 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 /> employ any person in such manner as to become subjectlo workman's compensation laws of California."Contractor's hiring or sub-contracting signature- <br /> certifies the following: "I certify that in the performance-oft he work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic must call f all re uired pections. Complete drawing on reverse side. <br /> Q Date: �� ITS <br /> Signed Title: — <br /> r FOR DEPARTMENT USE ONLY w. <br /> Date Area <br /> Application Accepted by �� QS <br /> I Pit or Grout Inspection by Date Final Inspectio Date J <br /> Additional Comments: <br /> '❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ 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 /> e r FEE AMOUNT DUE AMOUNT REMITTED, OK RECEIVED BY DATE PERMIT"N0. <br /> INFO r/.y� <br /> + EH 13.241REV.10/83) l `�.? �SsS 5`I <br /> EH 1426 <br />