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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �1 1601 E. HAZEL T ON AVE., STOCKTON, C <br /> Telephone (209) 466-6781 <br /> AJ I PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> C—'J e .. i tComplete in Triplicate? �QI <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal the work herein described. This application is <br /> I made in compliance with San Joaquin County Ordinance No. 549 ftbr sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. Z-3�^foo—'3 b <br /> ,5W ` / Z-a-.S— %­ ----3( <br /> Job Address �f�� 0 c.�u,�—T _ . - i_ City Lot Size PM <br /> Owner's Name Jam, Address Phone <br /> Contractor �L� ddre License No. Phone 1 —r•� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 63 SYSTEM REPAIR ❑ OTHER' � "(��a"r �}�c`� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE to is t,5O Oc[ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation <br /> `k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S�eeif+eai+eaae <br /> FI Public 1-1 Other ❑ Delta Depth of Grout Seal <br /> i I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Typv of Pump H.P. State Work Done _ Lr=- <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> i <br /> Depth Filler Material (Below 501 4A4 Z�7A4!1,I&A4t, <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> r <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line `. <br /> DISPOSAL PONDS El <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, an <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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." <br /> The applicantP11 c 11 for al Wired inspections. Complete drawing on reverse side. \ <br /> Signed X Title: GD6,6T Date: ` <br /> OR DEPARTMENT USE ONLY <br /> l Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: g T PGG Z 7 E V 6 AVIS - <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> Ek14-28 <br /> + E 11-28(REV.f i tt 51 —1 <br /> s V <br />