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. APPLICATION FOR PERMIT eii� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ? <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA , <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES VYEAR 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 Rules and Regulations of the San Joaquin <br /> Local Health District. ^ <br /> cat n <br /> Job Address City`-w"" '' Lot Size PM <br /> Owner's Name t! v""`< __ Address Y Phone <br /> r Address License No. 1 Phone <br /> Contractor Q 1 <br /> TYPE OF WELI_PUMP: -. _ NEW WELL ❑ WELL REPLACEMENT_❑ T DESTRUCTIO <br /> PUMP INSTALLATION}❑ SYSTEM REPAIR ❑ OTHER i_] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.^ - —PROP. LINE S„ <br /> FOUNDATION AGRICULTURE.WELL, OTHER WELL *PITS/SUMPS <br /> INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottorri C1 Manteca Dia. of Well Excavation Dia':;of Well Casing <br /> ❑ Domestic/Private 0 Grav l-Pack_ D.-Tracy Type of Casing f Specifications <br /> (1 Public n Other Cl Delta Depth of Grout Seal r�Type of Grout--- <br /> I <br /> rout -I I Irrigation _.Approx. Depth I 1 Eastern _ Surface Seal Installed by * _ <br /> Repair Work Done ❑ -Type.of.Pump..-�_H.P..- - -- - -- _State Work Done <br /> 1: <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth. Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION (No-septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— -Others` . <br /> E <br /> Number of living units: k Number of bedrooms - F <br /> Character of"soil to a depth of 3 feet: ; Water table depth <br /> SEPTIC TANK" ❑ Type/Mfg '! Capacity No. Compartments <br /> M PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 11� Foundation ' Property Line <br /> LEACHING LINE ' ❑ No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number t <br /> SUMPS LI Distance to nearest: Well Foundation I Property Line <br /> DISPOSAL PONDS ❑ <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. is <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 Califo nia." 1 11. - <br /> The applicant us call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: aA717 Date: <br /> FORT USE ONLY <br /> Application Accepted by Date L, Area <br /> 17 <br /> Pit or Grout Inspection by Date .FimaI Inspection by e. Date <br /> Additional Comments: �. /�/1� a rp -✓,1 7_ 'd`�. -7//,3 <br /> �❑ 5tk,�4&6-6781 --0-L-4 i--369-3621 ❑ Manteca_`82 -71'04­ ��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 AMOUNT DUE AMOUNT REMITTED ' CK —RECEIVED BY DATE PERMIT NO. <br /> INFO �7 CASH <br /> + EH13-241REV.rind ax <br /> .{ S ss- <br />[ EH 14.26 �CJ- <br /> Y <br />