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pi /Z.J- wa. ZJ3Z <br /> _,oQ/ <br /> APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'ea <br /> 1601 E. HAZELTON AVE., STOCKTON, CA idy <br /> Telephone (209) 466-6781 ��`(� ������ �'� �6O�G <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . 47;1«/17wT'eY- <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. 18662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. py <br />`. Job Address 3� Q � ✓ !/ <br /> City Lot Size C U l PM <br /> Owner's Name Address Phone <br /> Contractor's Name j%rLicense No. Phone 1 } <br /> TYPE OF WELL/PUMP: NEW WELL ❑ I 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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> ❑ Domestic/Private El Gravel Pack E3 Tracy Type of Casing Specifications <br /> i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal_ Type of Grout <br /> Ll Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P.- State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 UJ <br /> Depth . Filler Material {Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer_ is C I <br /> =--available-within 200 feet.) <br /> ! r <br /> Installation will serve: Residence 4 Commercial_ Other <br /> Number of living units:—I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: # Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1 RM No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispopal <br /> Distance to nearest:, Wei ndation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �? <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line } <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ -± <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i <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, l shall 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 1 <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 must call for quired ins ctio s. Complete drawing on reverse side. i / g-4� f <br /> 13 <br /> Signed Title: �� ^ ti� Date: / / ± <br /> —FOR"DEPARTMENT USE 1.ONLY' <br /> 1 <br /> Application Accepted byA Date �_8f Area <br /> t <br /> Pit or Grout Inspection by Date Final Inspection by /4 Li%% / Date <br /> i <br /> Additional Comments: le <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324(REV.10/83) y� <br /> EH 14-28 <br /> 1 <br />