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It. ION <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZEL`TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p <br /> } (Complete in Triplicate) 501 L �� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the-work he in described. TMs application is <br /> made in compliance with an Joaquin Co nn`{O dinance No.549 for sewage or No. 1862 for well/pump and t'ie Rules and Regulations of the San Joaquin <br /> Local Health Distr.' _ <br /> ` ff ✓ City Lot Size PM ° <br /> Joh Address � <br /> r 7/0 � r <br /> Owner's Name Address Phone <br /> e <br /> Contractor's Name i ense No. <br /> 3ik Z . Phone / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ---- •^'-WELL REPLACEMENT ❑ol,,. DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRf❑;"" OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES •DISPOSAL FLD. PROP. LINE <br /> } r FOUNDATION AGRICULTURE WELL OTHER WELL--PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom�❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private .1j'❑ Gra6e+ Pack f ❑ Tracy `Type of Casing Specifications <br /> 1 <br /> [D Public I El 01 t e�j 4 q ,.� L1,Deita pth-of Grout Seal Type of Grout <br /> L� _ I <br /> El Irrigation __Approxi Depth�❑:Eastee alnstalled by y F <br /> "Repair Work Done ❑ Type of Punn'­ H.P. State Work Done <br /> Well destruction t ❑ Well Diameter! Sealing Material,(top 50') .d <br /> �j°r_�Depth } Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is e <br /> iavailable within 200 feet.) <br /> In will serve: Residence Commercial� Other <br /> i Number of living units: Numbler of Brooms <br /> l <br /> Character of soil to a depth of 3 feet: I +Water table depth <br /> f i ° 7 t Capacity No. Compartments <br /> SEPTIC TANK ElType/Mfg _ t <br /> PKG. TREATMENT PLT. ❑ 1 Method o Disposal, <br /> } �� r <br /> Distance to nearest: 1NeIl � Foundation� •'Property Line <br /> LEACHING LINE L1 No. & Length of lines r Total length/size x �� <br /> FILTER BED Distance to nearest: Well Foundation!--, Prop� Line <br /> SEEPAGE PITS z ❑ Depth Size Number I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line P <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. <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 CaMornia." 1 <br /> The applicant must call for all requirao4pspections. Com ete drawing on reverse side. j <br /> Signed Title: Date: 1 p� <br /> f 5 <br /> I FOR DEPARTMENT USE ONLY <br /> Area <br /> Date <br /> Application Accepted by -""" " ' / �p <br /> Pit or Grout Inspection by Dated Final Inspection by Date <br /> Additional Comments: ` <br /> i ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> f - <br /> CK# <br /> ` FEE AMOUNT DUE ; AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> If INFO <br /> +EH 13.24(REV.101831 ��� fa'r3=�3 ��-l�' . p✓n'� � <br /> r <br /> EH 14-28 - -- <br />