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= APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA , <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> Ryles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordnance No.549 for sewage or No. 1862 for well/pump and the <br /> Local Health District. —2sq q <br /> Job Address4lq&Q <br /> Lot Size PM <br /> owner's Name ��' ��+" T 0 - Address <br /> � �s <br /> � Phone �%' <br /> jcn6t,e��yn^l 5 Yw nT;'� YS Address.21-2 O w1�C y LicenseNo.41 L4Phoneactor <br /> I <br /> TYPE OF WELL/PUMP: NEW WELL L1 WELL REPLACEMENT 11DESTRUCTION LJ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ It OTHER n j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial El Open Bottom <br /> EI Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Yp Type of Grout <br /> El Public El Other [5 Delta Depth of Grout Seal Yp <br /> ❑ Irrigation /---Approx. Depth 0 Eastern Surface Seal Installed by AAerx <br /> U <br /> Repair Work Done f�/ Type of Pump S� H.P. _ State Work Dane <br /> Well Destruction ❑ . Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50') y <br /> E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION EJ DESTRUCTION [Ialvailao sep iwthin <br /> sysm <br /> rmiitted if public sewer is U► <br /> i O <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 (A <br /> SEPTIC TANK ❑ Type/Mfg Capacity 'No. Compartments <br /> PKG. TREATMENT PLT.' <br /> F1 Distance <br /> of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ( <br /> Total length/size <br /> LEACHING LINE `❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1❑ Depth Size Number <br /> SUMPS t❑ Distance to nearest: Well Foundation Property Line rq <br /> l DISPOSAL PONDS ❑ <br /> 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 /> llowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the fo <br /> to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> employ any person in such manner as to become subject <br /> 1 certifies the following: "I certify that in the performance of the work forty hick this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call f re ired inspections. Complete drawing,on reverse s <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY �7 <br /> Date / J Area a <br /> Application Accepted by - 01 <br /> i — {Q <br /> Pit or.Grout Inspectiornby— Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 11 Manteca, 823-7104 E3 Tracy' 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.-O. Boz 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT`N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH EH 14-24(REV., <br /> /85) - / �� les q45 <br /> 4 <br />