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t <br /> l = d APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT • <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N o W'd <br /> t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED",z <br /> (Complete in Triplicate) <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 /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> .-. J ISI Vy Y <br /> Job Address l SA� S - City Lot Size PM <br /> Owner's Name P <br /> ry r Address -L/Z % A). ,5 g H A ST V4 €F Phone l 3 < a ZC <br /> ContractorY 11 r-i CW R1•D fLf L1 1aAddress / / d /0.GUI Zit4?nse No. �WQ <br /> TYPE OF WELL/PUMP:._ NEW WELL ❑ WELL 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 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r- <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> -�* - — <br /> O Public '❑ Other f ❑ V �Depthh of Grout Seal Type of Grout <br /> ❑'I'rrigation j �, Delta­ <br /> --Approx. Depth ❑ Eastern, Surface Seal Installed by <br /> f Repair Work Done ❑. Type of Pump H.P.. State Work Done <br /> WellDestruction 01 Well Diameter � Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> i vailable within 200 feet.) <br /> Installation will serve: Residence X Commercial_ Other ! <br /> Number of living units: Number of bed'rooms'°'""""'-' ►g"� <br /> Character of soil to a depth of 3 feet:' f Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PL ❑ i ; '. f { Method of Disposal <br /> Distance to nearest: '-Wali / Foundation Property Line <br /> LEACHING LINE ❑ No.-& Lengthf-lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth ~`j Size Number <br /> SUMPS ❑ Disiance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f t <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 for which this permit is issued, I shall not <br /> employ any person in such manned as to become subject to workman's compensation laws of California."Contractors 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 /> The applicant ust II for all re ui in l ions. C plate drawing on reverse sidr. <br /> Signed Title:' Date:., <br /> DEPARTMENT USE ONLY { <br /> Application Accepted by �,SlQun+Wl Date f�L `c Area <br /> Pit or Grout Inspection by Date Final Inspection by DAe �6 <br /> 1 <br /> f Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I INFO AMOUNT DUE ,yAN�� <br /> MOUNT REMITTED CASH RECEIVED BY -DATE PERMIT`NO. <br /> l EH 13-24(REV.1/65) ��'"^ .voi / ��f 1- <br /> + EH 14-26 "-1 [J <br /> I <br />