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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> App Y i <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 /> Q Q City <br /> Lot Size�-L�•-- PM i <br /> Job Address C� I <br /> /�U [ .4 ddress f Phone rr3 <br /> q�'2o! <br /> Owner's Name ' <br /> j l Phone 0 <br /> Contractor «1 '"D�Address /` !/ 1��� )License <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION i� PROP.-LINE <br /> ' SEWER LINES _"'�-"�DISPOSAi-FLD.y- •-_ . . . � <br /> DISTANCE TO NEA4S-f SEPTIC TANK pITSISLIMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom _ ❑ Manteca Dia. of Well Excavation <br /> I I❑ Industrial Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Y ❑ Tracy Type of Casing Type of Grout <br /> ❑ Other w n Delta Depth of Grout Seal <br /> C i Public a <br /> I I irrigation �..Approx. Depth I l Eastern Surface Sal Installed by <br /> j H.P. I. State Work Done <br /> I Repair Work Done ❑ •Type of Pump Sealing Material (top F� — - - - — V <br /> Well Destruction ❑ Well Diameter _ <br /> Depth Filler Material (Below.50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION I I DESTRUCTION 1,1 of o septic hite <br /> t m feet.) ;f public sewer is <br /> Installation will serve: Residence, Commercial— Other —� <br /> Number of riving units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type,Mfg Capacity <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P Y <br /> Total length!size <br /> LEACHING LINE ❑ No. & Length of lines T Property Line <br /> is <br /> FILTER BED Distance to nearest: Well Foundation <br /> Size Number <br /> i I Depth <br /> SEEPAGE PITS a <br /> SUMPS L-1Distanceto nearest: Well- _ Property p rtY Line <br /> 3 DISPOSAL PONDS ❑ <br /> 1 hereby certify that t 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 tris performance of the work for which this permit is issued, I shall not <br /> employ any person;n such manner as to become subject 10 workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> 6 certifies the following: "I certify that in the performance of the work fof which this permit is issued,1 shall employ persons subject to workman's compensa. <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> 111,7—The <br /> Title: Date:n <br /> t (Signed X <br /> FOR�DEPARTMENT USE ONLY `"!-7 1 I� <br /> Date "�! ..Area <br /> Application Accepted by * <br /> Pit or Grout Inspection by <br /> tl� Final Inspection by Date <br /> Date `—' "— <br /> Additional Comments: <br /> f ❑ Stk 466-6781 XLodiP.O. Sox 2009, 5tk., GA 95201 <br /> 369-3621 0 Manteca 823-7164 ❑ Tracy 835 6385 <br /> Applicant- Return allto: Environmental Health Permit/Services 1601 E. Hazelton Ave., <br /> FEE AMOUNT DUE OUNT REMITTED S RECEIVED BY DATE PERMIT NO. <br /> INFO �A_ <br /> +_EH 1321IREV.+/K51 <br /> fH t4-26 <br />