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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466=6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is helehy'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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> /b y-36 GX-ee�f �jtr�� city o e� Lot size PM <br /> Joh Address <br /> le �^ �s <br /> Owner's Namd��rGC� a <br /> afAddress ` ' 0'�dx`'-- Phone`s <br /> ss <br /> Contractor �, ra� �'� Addre �6 <br /> License No d.S7G Phone <br /> NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION.❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR*, OTHER <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES -��— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial [I open Bottom ❑ Manteca Dia. of f C] Weil Excavation Specifications <br /> t�Q Domestic/Private Gravel Pack ❑ Type of Casing Tracy Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other ❑ Delta <br /> Approx. Depth I 1 Eastern Surface Seal Installed by <br /> f'I(Irrigation State Work Done <br /> Repair Work Done 'it Type Of Pump H,P. <br /> f Sealing Material (top 50') <br /> Well Destruction LJ Well Diameter Filler Material (Below 501 <br /> ' Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIRlADDITION I 1 DESTRUCTION I i avlailablleseptic <br /> wthine200 feet.) if public sewer is— <br /> ' <br /> rn <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> ( Water table depth <br /> Character of soil to a depth of 3 feet: Compartments <br /> ❑ Type/Mfg Capacity No. <br /> SEPTIC TANK Method of Disposal <br /> I, PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> ` LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> 3 FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> " Size _ Number <br /> SEEPAGE PITS i I Depth Property Line <br /> l SUMPS ❑ Distance to nearest: Well Foundation _.��.— P y <br /> k '•.D&OSAL 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, an <br /> Tines.and regulations of the San Joaquin Local Health District. '!'" work for <br /> Home owner aor rson insuch manner toe certifies thebecome subject w1egkman'srtcompensation lify that in the awsoof Califormance rnia.e Contractor's hiring or sub-contracting signature <br /> l <br /> I employ any p arsons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p <br /> r tion laws of California." <br /> 6{ The applicant mus II r 1 required i ctions. Complete drawing on reverse side. <br /> Titley�a Date' <br /> Signed . <br /> FOR DEPARTMENT USE ONLY os <br /> - Date ^3 Area <br /> Application Accepted by �� — <br /> I Date <br /> Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Stk., CA 95201 <br /> Applicant- Return 11 Co.' s tot.Environmental Health PermitlSarvices.1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK <br /> EE AM NT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. <br /> INFO <br /> • ♦ EH 13-241REV.1/951 r <br /> EH 14-2e <br />