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�. ... <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s_ �.. ,�, , t {Complete in Triplicate) <br /> ' <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 /> " nty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulati <br /> made in compliance with San JoaquimCouons of the San Joaquin <br /> Local Health District. : .' i6 .. <br /> Fo City Lot Size' PM F <br /> Job Address � ,. <br /> / C./J�CE'� r�o0`G �� s / S _ Phone <br /> Owner's Name } <br /> 1 a Address Address License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP. NEW WELL El <br /> REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. • PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— pia. of Well Casing <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ' T of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack k ❑ Tracy Type Type of Grout <br /> ❑ Public ❑ Other T ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump _ ,, – <br /> a Sealing Material (top 501 s <br /> Well Destruction ❑ Well Diameter t <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0- REPAIRIADDITION ElDESTRUCTION ❑ (No septic sy tem rented if public sewer is j <br /> Installation will serve. 'dance_ Commercial- Other = <br /> Number of living units: Num Brooms Water table depth <br /> Character of soil to a depth of 3 feet: l <br /> acity No. Compartments <br /> # <br /> SEPTIC TANK ❑ Type/Mfg ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ " <br /> Distance+to nearest: Well Foundation rty Line <br /> i <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED El Distance to nearest: Well Foundation f <br /> ' Number <br /> SEEPAGE PITS El Depth Size Property Line <br />{ SUMPS O Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <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. I shall not <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, <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring <br /> ort -comm aning signatsa- <br /> ure <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ pe <br /> I tion laws of California." <br /> The applicant must call fo al1 r` e' ins ` coons. plata drawing on reverse side. <br /> u r" Hate: <br /> Title: <br /> Signed <br /> 1 _ _ FOR DEPA IYIENT US ONLY <br /> 7 D91 . <br /> ate ! Area pz <br /> Application Accepted by._ Date //f.Z <br /> f <br /> Pit or Grout inspection by ! Date Final Inspection by r <br /> Additional Comments: ❑ Tracy <br /> ❑ Stk 466-6781 ' ❑ Lodi. 369-3621 ❑ Manteca 823 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> •r <br /> FEE CK RECEIVED BY DATE PERMIT`N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> + EH 13-24(REV.118W <br /> Y' <br /> EH 14-26 <br />