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A APPLICATION FOR PERMIT f , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT (� <br /> 1601 E..HAZEL iON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> o <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> L (Complete in Triplicate) I <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 appricaLan's <br /> made in compliance with Sari Joaquin County Ordinance No.549 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. y 1 <br /> City Lot Size PM B <br /> Job Address �4 <br /> < .4 <br /> Owner's Name I f ' <br /> 1 SilYIS-' Address v Phone <br /> Contractor <br /> S� Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION LI SYSTEM REPAIR;❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES: <<`' . 'E DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial El open Bottom�'�'T""'❑-Manteca"' """""Dia sof Well'fxcavation— <br /> Specifications <br /> Type of Casin fications <br /> F1 Domestic/Private ❑ Gravel Pack ❑ Tracy yp g T e of Grout <br /> Ll Public ❑ Other ❑ Delta Depth of Grout Seal I yp <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H.P. <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 }} <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (NosbPtc s sthin 200 emitted if public sewer is <br /> all. f1 <br /> Installation will serve: Residence, Commercial=` OI _Jther - <br /> Number of living units: Number of bedrooms "'^ Water table depth <br /> Character of soil to aof 3 feet: No. Compartments <br /> ZType/Mfg <br /> SEPTIC TANK c1 <br /> Method of Disposal <br /> PKG. TREATMENT PLT. - <br /> ❑ Distance to nearestPenV �� ( I�f1t�l0U Property Line <br /> ted or InSnectPd <br /> l�I�nl'�I <br /> i <br /> ' `` T� ength/size <br /> LEACHING LINE ❑ No. & Length of lines F 5 ,. , {_ , I I <br /> kj _.;; � ;`* �'�` ourid'atlori r.,. Property Line <br /> FILTER BED ❑ Distance to nearest:' <br /> Size Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> ' ❑ Distance to nearest: Well Foundation <br /> SUMPS <br /> DISPOSAL PONDS ❑ -- <br /> I <br /> 1 hereby certify that I have prepared this application'and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> Nome owner or licensed agent's signature certifies the.fallowing: "1,certify that in the performance of the work for which this permit is issued, I shall not <br /> such manner as to become subject to <br /> employ any person in -.workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> I nce of the work for which this permit is issued,l shall employ persons subject to workman's compensa <br /> certifies the following: "I certify that in the performa <br /> tion laws of California." 1 <br /> The applicqnt/oqust call for all required ingpections. Complete drawing on reverse side. <br /> f Title: Date: <br /> Signed <br /> n� FOR DEPARTMENT USE ONLY <br /> _ w`}r°fes Date ��`�^� Area <br /> Application Accepted by <br /> Final Inspection by Date <br /> Pit or Grout Inspection y Date <br /> Additional <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L"di 369- 1 ❑ Manteca 823-7104 ❑ Tracy 8354385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BoxW-dr7 <br /> FEE AMOUNT DUE AMOUNT REMITTED S RECEIVED BY <br /> INFO 114 <br /> \✓+♦:EH 13-24(REV.1/85) <br /> EH 14-28 <br />