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T <br /> APPLICATION FOR 'PERM[It <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Citic,k A4 — <br /> I II <br /> 1601 E. HAZELTON AVE., STOCKTON, CA f re <br /> Telephone (209) 466-6781 <br /> r.. <br /> PERMIT EXPIRES'T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ion is <br /> Application is hereby^made to the San Joaquin Local Health District for a permit to <br /> 1862 Construct <br /> for and/or install and the Rues and Aegurk herein scribed of the Sant This cat Joaquin <br /> made in compliance with San Joaquin Couhty Ordinance No. 549 for sewage or <br /> Local Health District. <br /> Mel <br /> City * Lot Size M <br /> Jab Address <br /> Owner's Names Address <br /> V { Phone <br /> 4 <br /> Contractor � <br /> � dre5s c� t �`-' 1r License No. Phone <br /> TYPE OF WELLLPUMP:,,,.,,.«s,,..,..,_.-"NEW WELL ❑ WELL REPLACEMENT ❑ D <br /> PUMP INSTALLATION`❑ SYSTEM REPAIR .O OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; - <br /> INTENDED USE" TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> Ll Industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> a <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> fl Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _.-Approx. Depth l 1 Eastern Surface Seal thstalled by <br /> H p State Work Done <br /> Repair Work Done' 0 Type of Pump <br /> Well Destruction [7Well Diameter Sealing Material (top 501 <br /> 50 <br /> l <br /> l (B <br /> Filler Material 'I <br /> Depth �t <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION l No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence <br /> Commercial— Other <br /> Number of living units: Number of bedrooms " <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. CompartmentsIt <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance,to nearest: Well Foundation Property Line <br /> LEACHING LINE 1-1No. & Length of lines Tata) length/size <br /> FILTER BED L) DistanceF to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS 11" DepthSize Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ z <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 laws,and - <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issued, ].shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in:the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." j. <br /> it <br /> The applic ust call for all re fired' c 1 ns. mplete drawing reverse sid <br /> l Titl1. <br /> e: Date: <br /> Signed " i; <br /> FOR DEPARTMENT USE ONLY jr <br /> Application Accepted by Qate <br /> Area <br /> t Pit or Grout Inspectio Date Final Inspection by Date <br /> Additional Comments: <br /> C1 Stk 466-6781 ❑ Lodi 369-3621 r ,. ❑ Man ec 823 7104 ❑ Tracy 5-W5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. fox 2009, Stk., CA 95201 3' " <br /> S <br /> 'i <br /> L <br /> CK <br /> fF INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. } <br /> 1 + EH 13.24 1REV.1/N 5) � Po 3 S , 1�✓,� �� g*7 <br /> r EH 14-26 <br /> 1 <br />