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APPLICATION FOR PERMITt9a <br /> SAN J€MAZE T �HEALTH DISTRICT <br /> �' � t� V � w <br /> `V STOCKTON, CA <br /> E E I <br /> Telephone (209Y 4014ni <br /> PERMIT EXPIRE$1 YEAR FROM DATE ISSUED <br /> MAY g <br /> (complete in Triplicate) , ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct !/or install the work rain is <br /> rt is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.-1862 for well/piomp anothe Rules and Regulations of the San Jaagvut <br /> Local Health District, <br /> Job Address f "Z- // �.�.' r <br /> City X04LLot Size PM <br /> Owner's NameV Address Ja 43 '� �. /� Pho,34L —. <br /> Contractor's.Name 4 License No. G .13 ^D <br /> 7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION ❑ <br /> PUMP INSTALLATION Or SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL <br /> -- �- FLD. -_PROaP. LINE <br /> OFOUNDATION AGRiCUTMlUftE t <br /> -;. <br /> r#TSIS `S <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 15Urrigation �.Approx,Dept ❑ Eastern Surface Seal installed by <br /> Repair Werk Done ❑ Type of Pump H.P. .10 <br /> �� State Work Done <br /> Well Destruction ... 0' W4I1 Diameter Sealing Material (top 50') <br /> t } • nth Filter Material(Below 50,') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septi <br /> csystern permitted If pub6d,96tnsr is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Far <br /> Character of 96M to ardWo <br /> ofWater table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest; Well Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of lines Total lengthlsize ; <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Late <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Late <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this appkcation and that the work will be dock in accordancearith San Jo¢quin county ordinances,state laws,and <br /> rules and regulations of llae Salt,leaquiss Local,Weal `_ _ R <br /> Home owner or licensed agent's signalre certifies the following: "I certify that in the performance of the worfcwhiehthis perrrut is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of"California." s hiring or sub-contracting signature <br /> certifies the following:'h certify that in the performance of the work for which this permit is issued,l shell employpiwaons subject to workman's compensa- <br /> tion laws of Calffomia." <br /> The applicant tea for all re uired inspections. Complete drawing on reverse side. <br /> Signed X ')"-/.Title: 22 A: Z Date: <br /> /F0DEP TMENT USE ONLY <br /> Application Accepted by Date V0 '�q/Area <br /> Pit or Grout Inspection byDate Final Inspection by -CiTf+/ �Gt Q �' C(� <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 835-6396 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1001`E. Hazelton Ave., P.O. Box 2009,Stk., CA 96MI <br /> FEE AMOUNT DUE AMOUNT REMITTED CA <br /> INFO SH RECEIVED BY DATE PERMIT"NO., <br /> +EH 1324(REV.10/83) <br /> EH 14-T8 '' <br />