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�.: APPLICATION FOR PERMIT r <br /> SAN JOAQUIN10CAL HEALTH DISTRICT �A <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 1V Q � � /� <br /> Telephone {209} 466-6781 . <br /> PERMIT EXPIRES ,11 YEAR FROM DATE ISSUED: <br /> {Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to <br /> made in compliance with San Joaquiri County Ordinance No.549 for sewage or No.1862 for well/and/or <br /> and the work herein described. This San n is <br /> Local Health District. P P the Rules and Regulations of the San Joaquin <br /> .a <br /> Job Address cel . City ' Lot Size ` Q f Dr <br />` PM <br /> Owner's Name J°^L � _ Address 'k�-.1 <br /> c Phone <br /> Contractor J Address `J <br /> ^ License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP IN LLATION ❑ SYSTEM REPAIR ❑' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIQN GRICULTURE WELL OTHER W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCT CIFICATIONS <br /> ❑ Industrial ET Open Bottom ❑ Manteca D ell Excavation <br /> C1 Domestic/Private El Gravel Pack ❑ Tracy Type of C Dia. of Well Casing <br /> ' <br /> ❑ PublicSpecifications <br /> ❑ Other 11a Depth of Grout I <br /> 11 Irrigation ---Approx... <br /> Type of Grout <br /> De ❑ Eastern Surface Seal fnstalle <br /> Repair Work Done ❑ Type of P p H.P. State Work Done <br /> Well Destruction ❑ iameterx <br /> Sealing Material (top 50') � <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial_ Other available within 200 feet.) <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 . s <br /> PKG. TREATMENT PLT. E-1NoCompartment � <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> r Property Line <br /> SEEPAGE PITS ❑ Depth ISize Number <br /> SUMPS ❑ Distance to nearest: Well _ Foundation Property Line <br /> DISPOSAL PONDS ❑ y } <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signatureIcertifies the following. I certify t <br /> to an i 9� " �fy that in the performance of the work for which this permit is issued, I shall not <br /> em { <br /> P Y y 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." I <br /> The a licant must call for all required inspections. Complete drawing on reverse side. " <br /> Signed ) r <br /> Title: Date: <br /> RTMENT USE ONLY <br /> Application Accepted by <br /> Date �_�3^ Z <br /> Area <br /> Pit or Grout inspection by Date Final In Date <br /> Inspection by <br /> Additional Comments: t <br /> s <br /> ❑ Stk 466-6781 ❑ Lodi 369-362111 ❑ Manteca 823-7104 ❑ Tracy 83546385 F <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO SH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.1/65) Ud t <br /> EH 14-28 <br />