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APPLICATION FOR PER <br /> E (I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `' r1 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 1 <br /> Telephone (209) 466-6781 <br /> PER 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• f the his applrc is <br /> the Rules and Regulations of t <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and e San Jooaqaq is <br /> t Local Health District. <br /> city `± <br /> Lot Size PM <br /> Job Address <br /> ,—Phone A— <br /> FOUNDATION <br /> -.,AddressOwners-Name - 4._.L Phone <br /> ContractorAddressLicense No.���—NEW WELL ❑ SWECEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIP P: - > `` SYSTEM REPAiR ❑ OTHER ❑—PUMP-INSTALL-ATION ❑'* ' Y pISPOSALFLD. PROP. LINE*SEWER LINES f DISTANCE.TO NEAREST: SEPTIC TAMC PITS/SUMPl �AGRICULTURE WELL OTHER WELL <br /> INTENDED USE L TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> Dia:-of Well-Excavation <br /> Dia. of Well Casing . <br /> l ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � x <br /> f 0 Public ❑ Other <br /> ❑ Delta Depth of Grout Seal''° Type of Grout"- <br /> _ _�pprox._Depth ❑ Eastern Surface Seal Installed:by { <br /> ❑ Irrigations _ State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Weil Destruction ❑ Well Diameter Sealing.Material {top 501 <br /> _Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ avail bletwithin 200 feet.) 'rf public sewer is <br /> I Installation will serve: Residence Commercial Other <br /> Number of living units: Number o edrgoms� Water table 7depth <br /> j Character of soil to a depth of 3 feet: No. Compartments <br /> EPTIC TANK <br /> S - ❑. "Type/Mfg Capacity <br /> l - % Method of Disposal ' <br /> 1 PKG. TREATMENT PLT. ❑ ; Property Line <br /> I Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING.LINE""""'0`..NoT&•'Length-bf lines <br /> F - ` <br /> i Property Line –r- <br /> FILTER <br /> ' � <br /> I FILTER BED ❑ Distance to nearest: Well Foundation <br /> r <br /> ,� 44 -Size`'� 11CT Number r _ r <br /> SEEPAGE PITS ❑ Depth - <br /> SUMPS Distance to nearest: <br /> Well Foundation.. �— Property Line - <br /> DISPOSAL PONDS ❑ _ <br /> hereby certify that I have prepared this application and that the work QlI'tie done in accordance with'San Joaquin.county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. IF., <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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California:'Contractors.his subject <br /> contracting signature <br /> certifies the following:"1 cerfrfy that in the performance of the work-for which this.permit-is issued,[.shah' <br /> employ persons subject"to workman's compensa- <br /> I tion laws of California." ..,„ ,� -^� t po�-�The applicant must call for all required inspections. Complete drawing on reverse side:rH LL�VI 1Date.-Title:Signed s} ,DEPARTMENT USE ONLY <br /> I�� �. Date Area <br /> Application Accepted by �- r„ - r l � <br /> t Date Final Inspection by 4 Date <br /> Pit or Grout Inspection by <br /> Additional Comments: ! J❑ Tracy 835-6385' <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services1601 E. Hazelton Ave., P.C. Box 2009, Stk., CA 95201 <br /> * FEE <br /> CK, 17'RECEIVED BY � Y DATE PERMIT NO, <br /> INFO , AMOUNT DUE AMOUNT REMITTED 'CASK <br /> 1 .». 1Yyw..�.rr.+IM�-' ^"w4'a-'"'^"---' � '- _ - ��� ���..• ..s--x <br /> +EH 13-2A•IREY.,J/-a sl,r•:w'-'-� �� �. <br /> EH%28 <br />