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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> A / PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> li (Complete in Triplicate) nd/or lrcat;on is <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct aupur install the work herein described. This app <br /> : i <br /> compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for we <br /> made inlllpump and the Rules and Regulatio�is of the San Joaquin <br /> Local Health District. :E r��l <br /> Lot Size PM <br /> City� .� <br /> Job Address l <br /> -' Phone <br /> Owner's Name Address <br /> -�---• --_ _ `'^'.' e ' P Phone <br /> r `✓ Address <br /> Contractor ` ,e5, /4/69 A t License N1, <br /> /'�• o ( ,L DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: ... NEW WELL LJ WELL REPLACEMENT ❑ �I <br /> SYSTEM REPAIR E3 OTHER ❑ Ir <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> -, - SEWER LINES <br /> I DISTANCE TO NEAREST: SEPTIC TANK` PITS1SuMPS <br /> FOUNDATION ._�--- AGRICULTURE WELL OTHER WELL <br /> i <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of We111 Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑�Industrial Specifications <br /> I ❑ Domestic/Private ❑ Gravel Pack -':❑ Tracy Type of Casing - <br /> 1 Depth of Grout Seal Type of Grout <br /> [`l'Public t� Other n Delta I� <br /> Approxi Depth t I Eastern Surface Seal Installed by II <br /> I I Irrigation -- State Work Done <br /> Repair Work Done ED Type of Pump H.P. <br /> II <br /> Sealing Material (top 5011 <br /> Well Destruction LI Well Diameter <br /> h ! _ w •-- <br /> Dept ~ Filler Material 1Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t'1 REPAIRlADDITION DESTRUCTION l I aNailabPe'c system within 200 feet.)11 if public sewer is <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: -t— Number of bedrooms -- Water table depth <br /> t Character of soil to a depth of 3 feet: <br /> .l• y/I�&-jCe-r Capacity No. Compartments <br /> SEPTIC TANK ❑ TypelMfg Method of Disposal'��' <br /> PKG. TREATMENT PLT. ❑ T. f;*� ,, F� ;-� /��� <br /> Foundation�� - Property Line sem: <br /> y - Distance to nearest:, s£Well — <br /> N J=r Total length/size 4�l <br /> LEACHING LINE l�! Ni & Length�of tines � '^ <br /> '�f�Foundation-rp= Property Line <br /> FILTER BED ❑ Distance to nearest: Well t il� <br /> f Number a <br /> SEEPAGE PITS I I, Depth Size �I <br /> C7 Distance to nearest: Well Foundation Property Line <br /> SUMPS II. <br /> DISPOSAL PONDS ❑ -�` .-i --Z,- i '` <br /> 1 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 Di1itrict .- �� this ermit is <br /> Home owner or licensed agent's signature certifies the following: ertifymha'i i 1.on,laws of Califorrnia:"Zontractor'snce of the work for lhui g orr,suh contracting signature <br /> employemploy any person in such mannergw-to:become°subject to workman'sP persons subject to workman's compensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." 'r r <br /> The applicant must call for I required inspe ti ns. Complete drawing on reverse side. <br /> /ifr� Title: Date: . <br /> Signed X- el —� <br /> POR DEPARTMENT USE ONLY t <br /> Date <br /> • (�`1 iArea <br /> Application Accepted by r. 9/ Gr <br /> r Final Inspection by 4 l� v Date <br /> t. Pit or,Grout Inspection by Date s.I <br /> F � <br /> Additional Comments: <br /> ❑ Stk 466-6781. ElLodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 835.6385 <br /> yy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelto ,Ave., P.O. Box 2009, Stk., GA 95201 <br /> CK HECEIV.ED_f3Y_.x...'»e,_._DATE..,...._,.. :� PERMIT:NO..". .,:, .,m.�nrs'• <br /> /_ FEE,._ ,AMOUNT DUES.,.... ._-AMOUfdS 111 : 1 11 1 . CASH— <br /> �G lT 'INFO <br /> _ u <br /> r +.EH 13-21 REV.1 <br /> 4 <br /> EW 14-26 <br /> " <br /> v <br /> i' <br />