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t ` APPLICATION FOR PERMIT • <br />! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or <br /> l made in is hereby <br /> ma a to the SanJoaq <br /> Ordinalnce No.District Health 549 for sewage or No�1862 for cwell/pump install <br /> nd the Ryles and herein <br /> Regulations of the San Joaquin <br /> nce <br /> ith <br /> Local Health Di'strict.. 5�t7�o APC r T I C,. ` ` -I <br /> 1 b , \ C _ Lot Size PM <br /> sac City <br /> Job Address ++ /I .... <br /> l/�/Y k)VN Oil - - Phone <br /> Address <br /> Owner's Name - - <br /> Address <br /> License No.4'�bZSZ Phone <br /> �l Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER <br /> I PUMP INSTALLATION F-1 SYSTEM REPAIR ❑. .� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANK _ PITS/SUMPS —. <br /> FOUNDATION" AGRICULTURE WELL ' OTHER WELL <br /> -. . <br /> f INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION <br /> SPECIFICATIONS _ Dia. of Well-Casing <br /> { _ ❑ Open Bottom ❑ Manteca Dia. of Well vation _ - - <br /> t!t ❑ Industrial ❑ Tracy Type of Casing r - Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Grout �d G< <br /> ❑ Other ❑ Delta Depth of Grout Seal t f✓rC t<i��y <br /> f ❑ Public Surface Seal Installed by -� <br /> ❑ Irrigation �pPfOX. Depth ❑ Eastern _ - State Work Done <br /> H.P: <br /> _ - - Repair Work Done ❑_ Type of Pump Sealing Material )top 50q <br /> Well Destruction ❑ Well Diameter - - Filler Material (Below 609 <br /> Depth <br /> l - T available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Other— <br /> Installation will serve: Residence— Commercial <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: - Capacity—. No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg _ - Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation ' Property Line <br /> Distance to nearest: Well - - <br /> f <br /> - - - .. - - - Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: .Well <br /> .. .. <br /> Size_" Number - <br /> SEEPAGE PITS El Depth Foundation Property Line <br /> SUMPS El Distance to nearest:,- Well _ <br /> DISPOSAL PONDS ❑ - -- / <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, and- <br /> rules and regulations of the San Joaquin Local Health Districtg. at " or work f <br /> l not <br /> Home owner o lonenseuch manner as tobecomesubject s the Ito workman's com"I certify pensation lthe awsoof California." Contractors hiringl or sub-contracting l signature <br /> employ- I p p subject to workman's compensa- <br /> employ any pe <br /> certifies the following:"I certify that in the performance of the work for which this permit is Issued,I shall employ persons su I <br /> tion laws of Ceiifor 'a." <br /> The applicant m c II or required inspections. Complete drawing on rev l�rs i JI�T dtii w-�,'i Date: (� <br /> " Title: ��6 11 - <br /> Signed <br /> A T USE ONLY <br /> 1 / S"--Area <br /> 4 <br /> Application Accepted bye -/// Date - - Date <br /> Date Final Inspection by <br /> Pit or Grout Inspector y <br /> Additional Comments: ❑ Mante 873-7104 ❑ T Y / O D <br /> ❑ Stk 466-6781 ❑ Lodi 369- � , . CA <br /> Applicant ,- Return all copies to: Environmental Health Per <br /> mit/Services_1601 E. Hazelton Ave., P. Stk. <br /> FEE_ - CK 7t flECEIVED BY DATE -- PERMIT NO. - <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO '�c 1 <br /> 1 +EH 13-24(REV.1/55) ,p,e 613 �S Q <br /> i EH 1428 <br />