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t �7 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> I 9601 E. HAZE TION AVE., STOCKTON, CA <br /> Telephone (209) 466=67$1 <br /> PERMIT EXPIRES 7 YEAR'FROM DATE ISSUED ' °3.,:>tQ <br /> - (Complete in Triplicate)'-," <br /> Application is hereby made'to the San Joaquin LocalHealthDistrict for a permit to construct and/or install the wOredesC ba <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of <br />� local Health District. r� a, pplication is <br /> * y the San Joaquin <br /> Job Address �Q 1 �! L'1...;rz E 1 <br /> City '' Lot Size Y U <br /> sr. PM <br /> Owner's Name <br /> Address - ca •Z"�.�. - � <br /> Phone <br /> Contractor <br /> ,Address of <br /> TYPE OF WELL/PUMP: NEIN WELL LJ License No �-- Phon ^ / <br /> WELL REPLACEMENT ❑ DESTAUCTiON ❑ � i <br /> PUMP INSTALLATION �K SYSTEM REPAIR .❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> --^—_ SEWER LiNES ( , <br /> FOUNDATIONDISPOSAL FLD. PROP. LINE �f <br /> AGRICULTURE WELL OTHER WELLI <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ industrial <br /> 11 Open Bottom <br /> ❑ Manteca Dia. of WeIi Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑ Other f] Delta <br /> Delta ype of Casing Specifications <br /> CJ Irrigation Depth'of Grout Seal <br /> --Approx. Depth ❑ EasternSurface Seal Installed by TYpe of Grout <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ — H'P' State_ Work Done <br /> Well Diameter �_ Sealing Materia! {top 50') <br /> Depth Filler Material {Below 50') <br /> T <br /> PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ ;No septic system permitted if public sew <br /> Installation will serve: Res Commercial! Oflteravailable within 200 feet.) er is <br /> �, <br /> Number of living units: Numbe <br /> . edrooms� ,f <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK <br /> ❑ Type/Mfg x •: Water table depth <br /> Capacity <br /> PKG. TREATMENT PLT. L3 � � No. Compartments _ <br /> Distance to nearest: Well �.Method of Disposal <br /> Foundation's roperty Line <br /> LEACHING LINE ❑ 'No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: WellTotal length/size <br /> Foundation' Property Line <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Size Number <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS C] `°: r t- _ Foundation Property Line <br /> — <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 thetperformance of the wI <br /> ork for which this permit is issued, I shall not <br /> employ any penton in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the Performance of the work for which this ermit is issued, I shall employ <br /> tion laws of California.,, p <br /> p y persons subject to workman's compensa- <br /> tion <br /> applicant must c or all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ✓ <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> :Fi:rtal inspection by Date <br /> Additional Comments:La 11od! <br /> f' 1 <br /> ❑ Stk 466-6781 369-3621 ❑ Marlte623-7104 ❑ Tracy 8354SW <br /> Applicant- Return all copies to: Environmental Health Permit/Services 76011'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , <br /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED RECEIVED 13Y <br /> py <br /> CASH, DATE' PERMIT"NO. <br /> EH 13-24MEV.1/85) 7051 <br /> �� <br /> EH 14-28 <br />