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APPLICATION FOR PERMIT ® �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA OCT Z 9 19a� <br /> Telephone (209) 4666781 HEAL"A <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Vi 41Romf N "ICES <br /> (Complete in Triplicate) PORN( <br /> and/or install the work herein described. Tics application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit tO construct <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. 0,, /C At® 070 / /�, <br /> ;147 NZ, itv 4 Lot Size PM <br /> Job Address <br /> Phone <br /> Owner's Name,/�•� � �I � — Address ` <br /> PP�d _ License No. Phone 3 <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 <br /> �- - PUMP INSTALLATION �' " �' SYSTEM REPAIR Cl OTHER C7DISTANCE TO NEAREST: SEPTIC TAMC <br /> SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� <br /> Dia. of Well Excavation <br /> Dia. of Well Casing! <br /> ❑ [5Industrial ❑ Open BottE3Type of Casing Specifications <br /> um Manteca <br /> ❑ Domestic/Private ❑ Gravel P' k Tracy Depth of Grout Seal Type of Grout <br /> Public El Other ❑ Delta <br /> Irrigation ----Approx. Depth ElEastern Srrface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material (top 60') <br /> Depth Filler Material (Below 50') <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availablleseptic <br /> wthin200 feet.I if public sewer is <br /> x <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments A <br /> SEPTIC TANK ❑ Type/Mfg Capacity I+� <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ NO. & Length of lines Pro Line <br /> FILTER BED El Distance to nearest: Well Foundation Party <br /> 5 <br /> + - - - <br /> SEEPAGE PITS Ll Depth Size Number <br /> SUMPS <br /> _ v - E3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 District. <br /> ify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <br /> k such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in scertify that s the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies the following: <br /> tion laws of California." <br /> i The applicant call for all re uired ins ctio . Complete drawing on ravede. XPie- <br /> � 0 �� <br /> Title: Date: <br /> Signed <br /> FOJU2UJULU&LNT USE ONLY <br /> Date ® } Are <br /> Application Accepted by �}- <br /> 33 Final Inspection by Date <br /> Pit or Grout Inspection by I Date <br /> Additional Comments: <br /> ' ❑ Stk 466 6781 ❑ Lodi 369-3621 Il Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO RQ ^3q'46 .,r <br /> + EH 13-241REV.101831 ��� ^1 <br /> EH 14-26 <br />