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t� <br /> APPLI"CATION.FOR PERMIT <br /> u <br /> Y SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 r <br /> xa <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! . <br /> (Complete in Triplicate) <br /> vet. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs 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 qfthe�Joaqu <br /> " <br /> Local Health District. <br /> City S } Lot Size 'Y�Grp PM <br /> Job Address <br /> Phone <br /> Owner's Nam �� L Address <br /> Name" <br /> Contractor <br /> �I✓t�iL _ Address License No." i I> �L,9 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 4 PUMP INSTALLATION ❑ � SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ED industrial ❑ Open Bottom LlManteca Dia. of Well Excavation <br /> ` Dia. of Well Casing <br /> Type❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T YP of Casing Specifications , <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> l ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Deph Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION availableselwthssystem permitted if public sewer is <br /> Installation will serve: Res ence A orrmmercial._ 5l that <br /> - 1- - a`> <br /> Nurriber of livingzunitrs: 1- l Number ofbedrooms <br /> ' Water table depth <br /> Character of soil to a depth of 3 feet: r <br /> SEPTIC TANK F1 Type/Mfg` I Capacity IDC— No. Compartments J <br /> PKG. TREATMENT PLT. n + Method of Disposal t <br /> _. Distance"to_nearest.�.:.r Wel - Foundation Property Line 1 <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El -Distance.to nearest: Well. t Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS f ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ k <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.- <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 workmanfs compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ..�__ _.. persons subject to workman's compensa- <br /> i c rrifies the following: 1 ce that in the performance of the work for which this permit is issued,I shall employ <br /> tion a f California." <br /> The applican m all for all r uire spa t ons.ACplte,!3 wing on r verse side. 4� <br /> y Sign Title: <br /> Date: <br /> FOR DEP. TMENT USE ONLY _ <br /> –.- ---ate <br /> Applica`tiori'Accepted byCUP- <br /> ate ^Z [ G <br /> Pit or Grout Inspection by ' <br /> ifional,Comments:, _ - <br /> Stk 466 6781 ❑ Lodi 369-3621 _.❑_Manteca_823-7104"�, .. 7racyt_ 5-6385 P�--- •-� 4bVTrJ <br /> A plicint Return all copies to Environmental Health Permit/Seicis 1f907 E: H #on Ave.', P.O..Box 2009, 5tk., CA 952f11 � <br /> I , <br /> FEE IL CK RECEIVED BYKDATEE PERMIT'IVO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> r + EH13-24(REV.1/85) / Jr^ �'J O 9N, ZClO <br /> EH 14-26 <br />