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APPLICATION FOA PERMIT <br /> SAN JOAQUIN LOCAL .HEALTH DISTRICT.".' " <br /> l� 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS$UED'. <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for � '{ x + ' ` •. <br /> made H compliance with S�,Jo quUin County Ordinance No. 549 for sewage or No. 1852 for well/pump and.the Rules and Regulations of the San Joaquin <br /> Job Address <br /> City <br /> �"�j� > ,. <br /> Lot Size PM <br /> Owner's Name �` R <br /> Address . <br /> Phone' <br /> Contractor's Name <br /> A-k TYPE OF WELL/PUMP: License No. <br /> I NEW WELL ❑ — Phone,• <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> ❑`rA'',. <br /> PUMP INSTALLATION�'' SYSTEM REPAIR ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER El— SEWER LINES _ DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL f PROR.-,LINE <br /> INTENDED USE OTHER WELL PiTS/•SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Domestic/Private Dia. of Well Excavation <br /> ❑ Gravel Pack ❑ Tracy Type of Casing s <br /> ❑ Other ❑ Delta $peccations <br /> ❑ Irrigation "a, Depth of Grout Seal <br /> i' ,—Approx.,Deptstern Type of C,rout, } <br /> * Repair Work Donei s r p H.P- Surface Sea! installed by <br /> Type of Pum <br /> Well Destruction ❑, Well Dia_ter:_ "�P State Work Done <br /> Sealing Material (top 50'} ° <br /> Depth_ SBD�_ Filler MateHal (Below 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION ❑ (No septic system permitted if public r .P sewer is if <br /> Installation will serve: Residence— � available within 200#eat,1' <br /> Commercial# Other _ <br /> Number of living units: Number of bedrooms,' <br /> Character of soil to a depth of 3 feet: '-- --A.�•: <br /> SEPTIC TANK CI Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity. No. Compartments <br /> • f <br /> Distance to nearest: Well Method of Disposal <br /> y Foundation Property Line <br /> NLEACHING LINE -� <br /> ❑ No. & Length of lines <br /> FILTER BED 11' Distance to nearest: Well Tota! length/size <br /> Foundation .t w- Property Line_. <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS Size Number <br /> ❑ Distance to nearest: -Well Foundation f <br /> DISPOSAL PONDS ❑ -- Property Line , - <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 la <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: laws, and <br /> employ any person in such manner as to become subject to workman's compensationcertify laws of California."Pellormance Contractor,work for which <br /> opsub-conissued, I hallnot <br /> certifies the following; "1 certify that in the performance of the work for which this permit is issued, I shall em <br /> gnature <br /> tion laws of California." p W persons subject to workman's compensa- F <br /> The applicant st ca for all req fired i PpVions. Complete drawing on rev se side[ <br /> Signed t p,,� <br /> Title:_ Cf C" j s <br /> LO <br /> Date: " <br /> VV FOR DEPA MENT USE ONLY <br /> Application Accepted by <br /> Date Z ^�� Area <br /> Pit or Grout Inspection by -__ <br /> Date Final inspection by `- <br /> Additional Comments: ; Date <br /> ❑ Stk 466-6781 ❑ Lodi 369621 <br /> ❑ Manteca 823-7104 ❑ Tracy 835r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 5 <br /> FEEFUNT DUE t <br /> INFO AMOUNT REMITTED CK <br /> CASH ; RECEIVED BY <br /> DATE PERMIT'NO. <br />+ EH 13-24{REV.10/83)EH 1426 b0 . <br />