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APPLICATION FOR PERMIT 416�f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT }?Rjj <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 46E-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN 0 1 3990 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instaItl <br /> h <br /> s i his application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th� �CJdf the San Joaquin <br /> Local Health District. <br /> Job Address <br /> City 'r Lot Size PM <br /> f 7 <br /> Owner's Name - i iC¢-� � I Address 7" % t Phone <br /> Contractor Address ( �-� License Ny Ll�- _-Phone i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C11 SYSTEM REPAIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERJLINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑f Open Bottom F) Manteca Dia. of Well Excavation Dia. of Well Casing t <br /> ❑ Domestic/Private ❑jGravel Pack ❑ Tracy Type of Casing F Specifications (} _ <br /> f"1 Public f !Other 171 Delta Depth of Grout Seal Type of Grout—___ J I <br /> I I Irrigation -Approx.EDepth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Gil-' T e of Pum - <br /> Type p -- H. ! State Work Done <br /> Well Destruction EJ Well Diameterf5LA-A Z4 <br /> t Sealing Material (top 50'1 Zh <br /> Depth filler Material (Below 501) <br /> -TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION f I DESTRUCTION I I (No septic stem 4 <br /> P Y' permitted if public sewer is <br /> j ! available within 200 feet.) <br /> Installation will serve: Residence Commercial Other # '' <br /> Number of living units: f Number of bedrooms <br /> Character of soil to a depth of 3'feet: Water table depth <br /> a <br /> SERTIC TANK ❑ Type/Mfg E C ) <br /> } •-----•—. __ <br /> Capacity--L r No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> i Distance to nearest: Well Foundation I Property Line' <br /> r4 <br /> LEACHING LINE ❑ ?No. & Length of lines Total lengf)i/size <br /> FILTER BED ❑ {Distance to nearest: Well Foundation. Propei-t'y-yine <br /> 1 1' <br /> SEEPAGE PITS I I Depth Size lr <br /> SUMPS Number <br /> Ll Distance toynearest: Well Foundation 17 Property Line <br /> DISPOSAL PONDS © <br /> I <br /> I hereby certify that t 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 S'aA Joaquin Local Health District. <br /> Home owner or licensed agen't's signature`certifies the following; "I certify that in the perf Irmance of the work for which this permit is issued, I shat)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." F <br /> The applicant m st tali for all re uired inspections. Complete drawing on reverse side. <br /> Signed X <br /> -Title: Date: <br /> � f <br /> DR DEPARTMENT USE ONLYApplication Accepted by � Date � � <br /> • Area .2/ � <br /> Pit or Grout Inspection by } Date Final Inspection by�, '` Date C// t� <br /> Additional Comments: <br /> E Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH y <br /> ♦.EH14-24iREV.t/R51 �,00 i C' `� r�—��� i <br />