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—r - <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> Telephone (269) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> (Complete in Triplicate) <br /> Healtistrict for a pall the work herein describe application is <br /> Application is hereby made o loo Joaquin Counquin ty Ordinance lNo.D549 for sewage or FNo. 1862 for well/dPump atnd the R41es and Regukations of he San Joaquin <br /> made in compliance with Sanq <br /> Local Health District. <br /> �� .2� MLot Size `Ae PM <br /> .. City a <br /> Job Address 14� <br /> Address <br /> �, ,�. - Phone <br /> Owner's Name <br /> . = b Phone ��39 <br /> r f, Address �^!! License No. - <br /> Contractor DESTRUCTION.-O' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ;�i �. . <br /> S STEM REPAIR E rt'OTHER ❑ - <br /> PUMP INSTALLATION ❑ r V;j r PROP. LINE <br /> SEWER LINES) DISPOSAL FLDd. <br /> DISTANCE TO NEAREST: SEPTIC TANK '` "OTHER WELL- PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> the <br /> INTENDED USE TYPE OF WELL PROBLEM AREA '`'CDNSTRUCTION SPECIFICATIQNS i r <br /> Dia. of Well Excavation_ Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca l Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy I Type of Casing <br /> 4--Type of Grout <br /> ❑ Other ❑ Delta t + •Depth-of-Grout-Seal•'~ <br /> ❑ Public <br /> _--Approx. Depth ❑ Eastern Surface Seal Installed by : <br /> ❑ Irrigation State Work-Done— <br /> Repair Work Done E3 Type of Pump H p <br /> Sealing Material-Itop-50') <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION availableiw th n'.200 feetitted'rf public sewer is <br /> t � ' <br /> Installation will serve: Residence✓ Commercial_. Other <br /> Number of living units: Number of bedrooms.ate Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— No. Compartments <br /> SEPTIC TANK 0, Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest:. Well I sly C– A A <br /> ,f - T6al`length7"sizee <br /> LEACHING LINE No. & Length of lines T s <br /> party Line <br /> Foundation. Ute.Pro <br /> I FILTER BED ❑ Distance to nearest: Well Foundation <br /> I <br /> �1 Size iX Number <br /> SEEPAGE PITS a i'Depth _ fj ! property Line - <br /> SUMPS Distance to nearest. well�..— Foundation <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 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, I shall not <br /> to become sub cis iContractors hiring oIc <br /> signature <br /> mfy any Psosuls s f he wok for which thpermits issed,I shall employ persons subject to workman's ompensa- <br /> ees the following: certify that the performance r <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title: <br /> — - Date: <br /> Signed - <br /> FOR DEPARTMENT USE ONLY <br /> Date Area l <br /> Application Accepted , <br /> pit or Grout InspectiDate <br /> Final Inspection by Date <br /> ty� <br /> I - <br /> i <br /> Additional Comments: <br /> j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> j - CK 0 RECEIVED BY DATE PERMIT'NO.- <br /> FEE' AMOUNT DUE AMOUNT REMITTED CASH' <br /> INFO �] fI <br /> +EH13-24(REV.1/85) /, pD - <br /> EH 14-26 - .- <br />