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} <br /> . t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 3 <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 11 <br /> ,/` <br /> Job Address " r �` V Gf City v G Lot Size . PM <br /> Owner's NameAddress Phone ' <br /> Contractpr Address Po a01[ fu 4 License No. Phone - ! <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I I Public 11 Other [-1 Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation _Approx. Depth I I Eastern~ Surface Seal Installed by <br /> I Repair Work Done ❑ ,T e.of Pum <br /> p yp p H.P. State Work.Done <br /> i Well Destruction ❑ Well Diameter 1 Sealing Material (top501 S <br /> Depth 'Filler Material JBelow 501 <br /> F <br /> TYPE OF SEPTIC WORK: NEW INSTAt:LATION REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial'_ Other <br /> Number of living units: -A— Number of bedrooms 3 <br /> Character of soil to a depth f 3 feet: Water table depth <br /> SEPTIC TANK �ype/Mfg IlG e, ,Capacity .No. Compartments <br /> PKG. TREATMENT PLT. ❑ if f Method of Disposal <br /> Distance to nearest: Well fl ._ Foundation �_ Property Line IS: <br /> LEACHING LINE No.'& Length of~lines _ :.. Total length/size f <br /> I FILTER BED E] Distance Distance to nearest: WelFoundation': Property Line <br /> SEEPAGE PITS P Depth Size 1[ Number—! <br /> SUMPS *w ❑ Distance to nearest: Well_- Foundation Property-Line <br /> DISPOSAL PONDS ❑ ) <br /> i I hereby certify that I have prepared tHis application-and that the woik will be done in accordance with San Joaquin county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin.Local Health District. `4 ¢ <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 /> employ any person in such manner as tobecome subj6ct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:�Lcertify that in the performance of the.work for which this..permit-is_issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all r quit inspections. Complete drawing on reverse side. j <br /> Signed X ____._. Title ` .t/l ! Date: )tr)97 <br /> e i <br /> lill"OR DEP MENT USE ONLY 1;7- <br /> Application Accepted by I Date Area , r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEC.. INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PER IT' <br /> + EH 1324 IREV.)/s 5) .y // -- <br /> - EH 1 <br /> 4-2e <br />