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APPLICATION TOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTONL AVE.,ySTOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM-DATE ISSUED <br /> (Complete in Triplicate) <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 /> uin County Ordma ce N 549 for sewage or No- 1 r well pu p and the R41es and Regulations of the San Joaquin <br /> made in compliance with San Joa <br /> Local Health District. a�� , <br /> �" r <br /> `' City of Size' PM <br /> Job Address k <br /> 'Phone <br /> Owner's Name ,fo N d-a5 ` Address <br /> # , /�ilsverYC Address License No. Phone <br /> Contractor <br /> TYPE OF Wt=LL/PU1ti71P: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl � t <br /> PUMP INSTALLATION © SYSTEM REPAIR 11OTHER C] 9, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> TYPE <br /> -� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPECIFICATIONS,-._.•- <br /> _ Dia. of Wellasing y <br /> D Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation <br /> Type of Casing Specifications <br /> ,,O <br /> ❑ Domestic/Private ❑ Gravel Pack . .Tracy � 9 , <br /> -.-�-�-, ------��- T e of Grout <br /> �- ❑ Public ❑ Other T ❑'Delta Depth of Grout Seal Type `} <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done [DType of Pump <br /> H.P. State Work Done �F <br /> Well Destruction ❑ Well Diameter Sealing Material jtop 50') , <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AD TION ❑ DESTRUCTION ❑ available 5eptlwth ne rmiitt� if public sewer is <br /> ' 1 <br /> Installation will serve: Residence k� Commercial_ Other t I 1 <br /> Number of living units Number of bedrooms '" ! <br /> Character of soil to a depth of 3 faet: �� Water table depth <br /> 1 i Capacity t No. Compartments <br /> SEPTIC TANK I❑ Type/Mfg <br /> osaI <br /> PKG. TREATMENT PLT:© �,'�'" �-� fa t�lletliod of'Dis�p <br /> Distance to nearest: Well�� Foundation./�-�- IProgerty3Line 2 { { <br /> LEACHING LINE 115 No. & Len th of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: Well,/_ Foundation k V 77 �S r , roperty Line <br /> � } i <br /> SEEPAGE PITS ❑ Depth *e Number'+ w f <br /> --• .Pro a line <br /> I SUMPS ❑ Distance to nearest: ,,Well% - oundationW Property <br /> I <br /> � <br /> DISPOSAL PONDS Lly <br /> I hereby certify that I have prepared this application and that ilia work will be done in accordance.with San Joaquin county ordinances, state laws, and <br /> rules and regulations of t°he.San Joaquin Local Health Dist'ric't.` <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, l shall not <br /> employ any person in such manner as to becomesubjecf-to worltman+s compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I(certify that in the perfo'mance of-h"ork fol'which fi�s permit is issued,9sshall a;ploy persons subject'to workman's compensa- <br /> " <br /> tion laws of California. <br /> Complete dra <br /> The applicant must call r a e spec s. w ng on reVerrs-e side. f <br /> } <br /> z } <br /> Signed E Title: ., t.0 Date: [ f <br /> f i ) { <br /> - FOR DEPARTMENT USE ONLY <br /> / <br /> I Application Accepted b 1 Datek <br /> Pit or Grout Inspection by <br /> to Final Inspection b te <br /> t "a <br /> Additional Comments: �� t <br /> ❑ Stk 466-6781 C] Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy ; . <br /> fApplicant- Return all copies to: Environmental Health PernlitLServices 1601 E, Hazelton Ave.,_P__O. Box 2009, Stk., CA 95201 <br /> FEE .. MO_UNT DUE AMOUNT REMITTED CK# REGEIVED.$Y „., DATE r PERMIT:NO.. <br /> -INFO- - --. .CASH... *. <br /> I + EH 13-24(REV.1/8 5) <br /> F <br /> EH 1426 - _ - <br />