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>I <br /> APPLICATION FOR PERMIT G <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 h <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) A.This <br /> or <br /> ll the work <br /> made Applicationcation is <br /> comphance w th Sanothe San Joaquin Joaquin County Ordinance No.District Health 49 for-sewage or permit <br /> 1862 for well pump and the Rules and hereinR Regulations of he San!Joaquin <br /> Local Health District. /� /-0— <br /> P <br /> City Lot Size PM <br /> Job Address <br /> Owner'N me_ I <br /> Address Phone <br /> '00111 <br /> Phone <br /> Contractor's Name License No. <br /> NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11TYPE OF WELL/PUMP: OTHER ❑ <br /> INSTALLATION`I PUMP ❑ SYSTEM REPAIR ❑DiSPOSAL <br /> _ <br /> SEWER LINES -.� FLD. PROP.__ LINE <br /> DISTANCE TO NEAREST? PTIC TANK ___ -- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> T e of Casin Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout <br /> ❑ Other 1 ❑ Delta Depth of Grout Seal yp <br /> f! ❑ Public i•' <br /> ❑ Irrigation J4pprox.'Depth ❑ Eastern _ Surface Seal Installed by <br /> ' W P , State Work Done <br /> i Repair Work Done ElTyQe of Pump - <br /> Well Destruction ❑, 'Well Diameter Sealing Material (top 50'1* <br /> Depth. <br /> 1 <br /> .-Filler-Material (Below 50'1 <br /> TYPE OF-SEPTIC ANEW INSTALLATION REPAIR7ADDITION.❑ DESTRUCTION ❑ aNailablQelwt system 204 feet.) <br /> Ftted if public sewer is <br /> Installation will serve:�'Rsidence_ Commercial Other <br /> .. . <br /> Number of living.unts:- I—;-Numbet of bedroom%__Z , <br /> •-�^ �" Water table depth ' <br /> Character of soil to a depth of 3 feet fjQ .,No. Compartments <br /> SEPTIC TANK Type/Mfg Capacity1�_ <br /> Y t -.Method of Disposal _ <br /> PKG. TREATMENT PLT. ❑ I . h <br /> Distance to nearest:' Well Foundation - -A Property Line- - �- �o" <br /> ? - 'total length/size <br /> 'r LEACHING LINE ❑ No. & Length of lines <br /> Distance to nearest: Well Foundation i+ Property Line�z-- <br /> FILTER BED <br /> ! _ -- `. Number <br /> SEEPAGE PITS ❑ Depth:� --Size- <br /> [ SUMPS ❑ Distance,to nearest: Well "' Foundation -~� Property Line <br /> I <br /> DISPOSAL PONDS ❑ r <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 District. {+� <br /> I Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shall not <br /> I employ any person in such manner as to become subjectto_workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> f. <br /> tion laws of California." �e <br /> The applicant must call for 11 equir nspecti ns. Complete drawing on reverse side. _ _— <br /> Signed Title: ` <br /> h, Date: 104 <br /> I FOR DEP RTMENT USE ONLY t �a j�'^"� <br /> _L0 T '�=_�� - Date V r Area <br /> Application Accepted by } - <br /> t Date Final Inspection b Date 7 <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 CI Lodi 369-3621 \OO Manteca 823-7104 -kA \❑"Tracy X835-63% <br /> CA 95201 <br /> I Applicant- Return all copies to: Environmental Health Permit/Servi6as 1601 E. Hazelton Ave., P.O. Box 2009, Stk., <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> pa NN Ip-110— ITY-1337 <br /> +EM 13-24(REV.101831 <br /> EM 14-26 —.. <br />