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C 3 � 3G <br /> APPLICATION FOR PERMIT <br /> rt SAN JOAQUIN LOCAL HEALTH DISTRICTJ �,n_� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �/f(} "•'�-, <br /> Telephone (209) 466-6781 �� 1 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED 4 <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 /> 15 L - f <br /> ,Job Addres � ��-,� City 0 Lot Size a � I �� PM <br /> ij <br /> S/ <br /> Address Phone �p�+C�� <br /> Contractor !� _Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: `` NEW WELL 0 C1WELL REPLACEMENT DESTRUCTION ❑ <br /> I!° <br /> PUMIP INSTALLATION ❑ SYSTEM REPAIR ❑ OT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OT ELL-- PITS/SUMPS r <br /> k, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Cl Manteca Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private. ❑ G'avel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public x n Other elta Depth of Grout Seal Type of Grout _ <br /> I Irrigation -,Approx. h l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Ty ump H,P. State Work Done I <br /> ih <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> DeptFll Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEWIce INSTALLATION I 1 REPAIR/ADDITION IJ DESTRUCTION { (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: resideCommercial_ Other <br /> 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 /> PKG. TREATMENT PLT. ❑. 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: WellFoundation Property <br /> 'Line <br /> SEEPAGE PITS I Depth Size _ Number <br /> SUMPS Cl 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 SanlJoaquin 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 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." 11. <br /> ". <br /> The ant m st 11 for all re. ed spections. Complete drawing on reverse side. <br /> Sign d X �St _g I. y L Title: —LLL, Y� *� Date: ,2"6-�_ <br /> i� FOR DEPARTMENT USE ONLY �J <br /> Application Accepted by Date/ � r Area i! <br /> Pit or Grout Inspection by ryl Date Final Inspection by Data <br /> Additional Comments: P© CA VZ-t L/ <br /> ❑ Stk 466-6781 - ❑ Lo 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _ <br /> Applicant - Return all copies to: <br /> IEnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201 <br /> 'll <br /> FEE <br /> INFO AINQUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> �/ <br /> ♦.EH 1324{REV.r/85Y <br /> EH 14-2e ns <br />