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APPLICATION FOR PERMIT C-3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> (Complete in Triplicate) plication is <br /> aquin /or install the work herein described. This ap <br /> Application 1s G nce with a to the San Jo <br /> County ordinance lNo.District Health 549 for sewage or permit <br /> 1862 forcwell/dpump and the Rules and Regulations of he San Joaquin I <br /> made in comp f <br /> Local Health District. z <br /> Lot Size �O PM i <br /> Job Address f�`� <br /> Phone 6 <br /> Address <br /> 0 Name <br /> Phone <br /> ontractor <br /> '"Address License IVa._�� <br /> TP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> YPE OF WELL/PUM + <br /> 1 PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR L] PROP. <br /> ❑ <br /> SEWER LINES_ = DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK - PITS/SUMPS <br /> IFOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA'i `CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ industrial ❑ Open Bottom,.. ❑ Manteca R_, ., Dia. of Well Excavation ; <br /> ' ❑ Tracy Type of Casing t Specifications <br /> ❑ Domestic/Private <br /> LJ Gravel Pack l Type of Grout <br />` Depth of Grout Seal <br /> ❑ Public # ❑ Other ❑ Delta <br /> El Irrigation --Approx. Depth Ll Eastern Surface Seal Installed by k <br /> H P State Work Done <br /> Repair Work Done ❑; Type of Pump I i <br /> Well Destruction ❑I Well Diameter Sealing Material (top 50'1 <br /> Depth I 1 Filler Material IBelow 501 � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑, (No septic th system permfeetltted if public sewer is <br /> lL `�� ®`" <br /> Installation will serve:+ Residence Commercial Other f <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type Capacity <br /> SEPTIC TANK t Method of Disposal ��— <br /> PKG. TREATMENT PLT. ❑ Property Line ' <br /> i Distance to nearest: Well ¢ Foundation � <br /> Total length/size <br /> LEACHING LINE ElNo. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P rty <br /> 1 <br /> ❑ Depth Size Number <br /> F SEEPAGE PITS Property Line <br /> SUMPS El Distance to nearest: Well Foundation <br /> DISPOSAL PONDS I❑ �'� fr' e-' r <br /> I 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 /> 1. <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> rmance of i l not <br /> Home owner or licensed agent's signaturecertifies <br /> subject the folio ing:" I cean'srtify <br /> that inthe t on la ,CaliforniahB Contract which <br /> ring or sub-contracting signature <br /> employ any person in such manner as become <br /> certifies the following:'9 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> 1 tionlaws of Cali rnia.'" i \ ` <br /> 4 The applicant st call for all required inspections. Complete drawing on reverse side. } <br /> r ,,, '> ' Date: <br /> Signed <br /> Title: <br /> ,. <br /> FOR DEPARTMENT USE ONLY <br /> ` .Date <br /> Area <br /> Application Accepted by <br /> Date___� Final:I spection by " <br /> Date <br /> Pit Ir-Grout inspection by ,., ell t { <br /> Additional Comments' �q� ,,,�rll <br /> ❑ Stk 466 6791 ' ❑ Lodi Manteca 823 7 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CKRECEIVED BY DATE PERMIT NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> l- + EH 13-24(REV.1/85) <br /> EH <br />