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4 ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ®� Telephone (209) 466-6781 <br /> L 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> / r <br /> Job Address / 4. <br /> City Lot Size ./ t 4 �j t� <br /> PM <br /> Owner's Name �r�� <br /> irtiddress Phone <br /> Contractor Address 1r�Q <br /> TYPE OF W—ELL/Pu p: AFaicense No. 46rff,11� Phone 07 <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK "g SYSTEM <br /> OTHER F11 <br /> t SEWER LINES DISPOSAL FLD. <br /> FOUNDATION PROP. LINEN <br /> —�� AGRICULTURE WELL _�� OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> ❑ Industrial ❑ Open•Bottom �____ 1� <br /> ❑-Manteca pia. of Well Excavation <br /> ❑ Gravel Pack Y` Dia. of Well Casing (11 <br /> Domestic/Private ❑ Tracy T <br /> f'l Public ype of Casing s Specifications <br /> Cl Other n Delta Depth of Grout Seal (� <br /> 1 I Irrigation � ..Approx. Depth I 1 Eastern Type of Grout �uy r � <br /> Surface Sea[_Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H,P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material trop 50'1 <br /> Depth Filler Material (Below 5011 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION !1 REPAIR/ADDITION i 1 pESTRUCTION i I [No septicsystem permitted if public sewer is <br /> Installation will serve: Residence Commercial <br /> available within 200 feet.) <br /> Number of living units: <br /> Other --- <br /> Number of bedrooms r <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg -�^ - Water table depth <br /> - ... i <br /> PKG. TREATMENT PCapac ��_ <br /> LT. ❑_ tyNo. compartments <br /> Method of Disposal r <br /> Distance to nearest: Well " ' <br /> ----� Foundation�_ property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearesi:- VVeII �I <br /> Foundation 44 <br /> f Property Line <br /> SEEPAGE PITS VI Depth t _ + <br /> SUMPS Size i Number <br /> Ll Distance to neites -" Well t <br /> DISPOSAL PONDS p Foundation ;F <br /> l' <br /> Property Line <br /> I hereby certify that I have prepared this application and Ithat 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 followin r <br /> fy <br /> employ any person in such manner as to become subject to wo kma6's compensation laws' <br /> that in the f Califomiahe Contrawork ct which this permit is issued, I shall not <br /> certifies the following: "I certify that in theors hiring or sub-contracting signature <br /> tion laws of California. ' performan 'uf the work for.whicli this-permit is issued, I shall employ persons subject to workman's compensa- <br /> The applicant o II re� � <br /> ctlons. Complete drawing on r ver side. <br /> Signed X !!/ Z�Wa& r <br /> Title_— <br /> Date: <br /> FOR-DEPARTMENT USE ONLY <br /> Application Accepted by ' € <br /> Date `2Z Area ' A <br /> Pit or Grout inspection <br /> Date J Final Inspection by , <br /> Additional Comments: -Date) -2 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 - Ma 823= Tracy"835-6385 <br /> 7104 "- <br /> ❑ <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601'IE. Hazelton Ave., P.O. Box 2009-'Stk., CA 95201 <br /> FEEDUE _ <br /> INFO AMOUNT AMOUNT REMITTa=D CK <br /> CASH , RECEIVED BY DATE <br /> +.EH 13-24(REV,,/K 51 PERMIT'NO. <br /> EH 14-26 © - �� SIZ7 <br />