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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCACHEALTH DISTRICT <br /> r <br /> 1601 E. HAZE T ON A1/,E., 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 /> 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. °" $`_"a I .. "' i ' <br /> Job Addres��'}}`L� /U ! /J1fYr�1c Q LU I P�" i" b' .t 1 i a City r�Q� 1 Lot fSLize p � t� <br /> Owner's Name a Addre wo <br /> Contract,& Address d License No one <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION, SYSTEM REPAIR_ X OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> b' tT—FOUNDATbON ' D AGRICULTURE WELD," 'OTHER WELL PITS/SUMPS G <br /> INTENDED USE�� TYPE OF'WELL� PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial y`+' F1 Open Bottoms El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private y ❑ Gravel Pack ��^^ ❑ Tracy Type of Casing Specifications <br /> ❑ Public a ❑ Other ❑ Delta Depth of Grout Seal <br /> _ p Type of Grout � <br /> ❑ Irrigation i --Approx. Depth ❑ Eastern Surface Seal Installed by / <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done a ' e in fl <br /> Well De ..❑ .Well-Diameter Sealing Material {top 50'1a Sp S- 0 , <br /> '1 <br /> f <br /> Depth Filler Material (Below 50 . w ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) 01- <br /> '_� Installation will serve: Residence Commercial_ Other <br /> Number of living units:J_ =Number of bedrooms <br /> Char'ter of soil to a depth of 3 feet: 'Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ —r- Method of Disposal + <br /> Distance to nearest: Well Foundation Property Line ` <br /> L .4 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t <br /> SEEPAGE PITS ❑ Depth -'Size Number " f <br /> SUMPS ❑ Distance to nearest: Well Foundation. Property Line <br /> 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. i <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 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 /> ,The applicant must call for all required inspections. Complete drawing on reverse side. <br /> � b y 3` <br /> Signed Title: fAl (� i'� Date: <br /> i >` FOR DEPARTMENT USE ONLY I <br /> AppNcation Accepted by Date ��Area ! <br /> Pit,:,,Grout Inspection by v Date Final Inspection by Date ) <br /> Additional Comments: ' <br /> © Stk-466-6781 Lodi 369-313321 ❑ Manteca 823-7104 _ _❑ Tracy 835-6385_ <br /> (Applicant=Return all pies to tEnvironmental Health.P6RFlii/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t .'A <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. k <br /> INFO CASH <br /> +EH 3-24 <br /> EH 14-261REV.1/85) t ' \ CLQ OZILi <br /> Fv -- <br />