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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �} <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA }� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> s Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the her i <br /> as kation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or,No. 1862 for well/pump and the Rul <br /> Local Health Digftitj� / <br /> Job Address _ City:jAA� Lot Size PM <br /> Owner's NartSe� Address Phone <br /> 4 <br /> r' <br /> qfi <br /> &a- <br /> Cont AddressEZ— License Nof Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public In Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation w""Approx, Depth l I Eastern Surface Seel Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑. Well Diameter Sealing Material (top 50') i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPADITION I ) DESTRUCTION I ] {No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other ! <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 13Type/Mf <br /> 9 Capa <br /> -- city No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Welvr—c DFoundation_�� Property Line <br /> LEACHING LINE ❑ No. & Length line —� 1 <br /> r F g Total length/size <br /> `FILTER BED r ` <br /> IDA'biitanci6 Wel) F f� <br /> to nearest _ Foundation Property Lie�- r <br /> 's-`'�+ -.'k "�..+, ice. � n :� u� - •&� r,;it, y + . <br /> EEPAGE PITS � R <br /> _ x f t Depth � :fSize xy x Number ° 1 <br /> r <br /> Q, Drstance toinearest: R.R. Well" -� Foundation pPropertyLrr a �`Am <br /> DISP_OSA! PONDS tt i � i # <?i r' �„,YC '"�` &. �a e b aF , ? ` ' �... E,., . ^ 4L} <br /> �. ereb Cie t-f. r ,t'r p•r�ppims.^�ttM.a -t ��' #-r' r+-+� r�-,e• ^^.•a c t s SBS,^StB�taWS <br /> ► Y this a icatlan and that the work wl11 be Bone n accordance,Mr!h`San O 'couunty ro dinanc <br /> 1or:le ffat: o uj1Wj of,. D—Q- x i <br /> ` s slgnattrte certif fo o`w'ing:_ `f oertify�tha rvtF r o�rman`ce of the work fof`ttifnclt this permit.is tssu I°shall°notes f <br /> � °Yf ..YtP� rA„ manna:as°fn become suem <br /> '" "rte <br /> -sem ,neiiib—to workman s cornpensatton laws:of Calrfomra Contractors htnrtg or su1wcontracting signature <br /> cartifiest�refollowrn }'r a n s t Rw rA w wm H;?" rz .c <br /> -,, Tr,.,, 11. "9 �fy th� in the _ Ace of the work for which thrsKpermrt is issued 1 shall employ persons subiect G. roan.s Mm " <br /> S _ R` VIfOCaldomi8. i C fi ;v " <br /> MAI- <br /> � �r � �,�,� �- ,:a�:,r <br /> an Complete gJan side <br /> Signed y - g <br /> rtle: Date: <br /> - FOR DEPARTMENT USE ONLY <br /> Application Accepted.b' Date Are ' <br /> Prt or Grout inspection Date Final Inspection by pate <br /> °Additional Comments:"" <br /> ❑ Stk 466-6781 0 Lodi 369.3fi21 ❑ Manteca' 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520' ' <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTEO CK 1 <br /> INFO y� CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 24 IFtFV.!/x sl <br /> IC7 7® rer" <br /> EH tM26 <br />