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---------------- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> � <br /> Telephone (20g) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> Application is hereby made to the San Joaquin Local Health District(Complete permit Tto Triplicate) <br /> made H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules <br /> Local in co District, <br /> construct and/or install the work herein described. This application is <br /> and Regulations of the San Joaquin <br /> Job Address l.� � � L <br /> a City �' "-"{ Lot Sire <br /> Owner's Name r PM <br /> Address <br /> Contracto Phone <br /> � ddres <br /> TYPE OF WELL/PU License No <br /> NEW WELL ❑ WELL REPLACEMENT QPhone <br /> i PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE,TO NEAREST: SEPTIC TANK SYSTEM REPAIR E3 <br /> ��- OTHER ❑ <br /> ! FOUNDATIOSEWER LINES N DISPOSAL FLD._�4 PROP. LINE <br /> PROBLEM <br /> AGRICULTURE WELL - <br /> INTENDED USE TYPE OF WELL OTHER WELL�� PITS/SUMPS <br /> AREA <br /> ❑ Industrial:"`"'- -'='= - �.� CONSTRUCTION SPECIFICATION <br /> EJ OPen"bottom ❑ Manteca S <br /> ❑ <br /> Domestic/PrivateDia• of Well Excavation <br /> t`l Public <br /> ❑ Gravel Pack ❑ Tracy T Dia. of Wel! Casing <br /> C7 Other Type of Casing <br /> f I Irrigation Cl Delta Depth of Grout Seal Specifications <br /> --..Approx, Depth I 1 EasternType of Grout <br /> Repair Work Done ❑ Surface Seal Installed by <br /> Well Destruction --. <br /> Type of Pump H.P.❑ Well Diameter State Work Done <br /> Sealing Material Itop 50'1 t <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !.7 REPAIR/ADDlTIDN i 1 DESTRUCTION <br /> septicsystem permitted if public sewer.is <br /> Residence -'"""x""'""�--available within <br /> Installation will serve: <br /> 200 feet.! <br /> Number of living units; Commercial Other <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ "Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ t Capacity__ No. Compartments <br /> J <br /> Distance`to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING.'LINE ❑i No. & Length of lines <br /> FILTER BED 01 Distance to nearest: Well-�� Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS I I ` Depth <br /> SUMPS Size Number <br /> Cl z Distance to nearest: Welli <br /> DISPOSAL PONDS © Foundation Property Line <br /> I hereby certify that I have prepared this application and-that.the-work~wirl.be-done.in-accordance-with San Joaquin county ordinances <br /> rules and regulations of the San Joaquin_Local_Health District."---.--_�. . <br /> Home owner or licensed agent's signature certifies the followin s state laws, and <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 /> g: certify that in the performance of the work for which this permit is issued, I shall not <br /> certifies the following: "I certify that in the Performance of the-work.for which this Permit is issued,.I shall em to <br /> Tion laws of California." <br /> P Y•persons subject to workman's compensa- <br /> tclfqThe applif "nspections. Complete drawing on rev se side. <br /> Date: <br /> Signed X <br /> Title: � �j <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> "Pit or Grout inspection by Date Area <br /> Date Final Inspection by <br /> dltlonal Comments: <br /> Date <br /> Stk 466-6781 ❑ Lodi 3fs21 ❑ 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 <br /> INFO RECEIVED BYDATE PERMIT NO. <br /> 30 <br />