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II. <br /> II <br /> �I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> II 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED J 19 <br /> (Complete in Triplicate) SEP 2 <br /> I <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc�r E?gd plication is <br /> ,,�� (�S}114s1 a an Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 far wall/pump and thefMl� �� <br /> Local Health District. III I ` <br /> Job Address Cit Lot Size PM <br /> .�I e <br /> Address _ Phone <br /> Owner's Name <br /> 28 <br /> Contractor II Address' r License No. 3 Phone � 1 7 <br /> 1 <br /> 1 TYPE OF WELL/PUMP: NEW WELL LIWELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITSlSUMPS` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial {-]'IOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑'Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public n, ther Cl Delta Depth of Grout Seal Type of Grout — <br /> I 1 1 Irrigation i! ..Approx. Depth 1 1 Eastern Surface Seal Installed by - <br /> ! State Work Done <br /> Repair Work Done DType of Pumpy,_� H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> �I available within 200 feet.) <br /> OQ <br /> Installation will serve: Residence— 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - Method of.Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ l No. & Length of lines Total length/size <br /> FILTER BED - ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F 1: Depth Size f Number <br /> SUMPS L-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify thit't­have 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 for which this permit is issued, I shat! 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." <br /> f TheaTitle! Date: <br /> d pplicant mus I for all required inspections. Complete drawing o reverse side. <br /> Signes <br /> k X l�. <br /> k �'' <br /> $. .II <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ! r l Date /� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date /1641, <br /> Additional Comments: I� <br /> M Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant - Return all copies` to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> N <br /> ` FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO ®� <br /> r..EM t3-24IREV. �g�'�—b �p <br /> EH 14-26 <br /> s � <br /> I _ <br /> µ <br />